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(Haih^t  nf  pijgBirtauH  anb  ^urgputtH 


.^r.^..C....i=^..L)^.uLi^lh.e.v:. 


THE 


DISEASES  OF  CHILDEEN. 


BY  THE  SAME  AUTHOR. 

HEADACHES:  Their  Causes,  Nature,  and  Treatment. 
Third  Edition.  Revised  and  Enlarged.  i2mo.  Cloth.  Price, 
$2.00. 

"  Dr.  Day  brings  to  bear  upon  his  subject  a  large  amount  of  experience  and  medical 
knowledge,  and  makes  many  therapeutical  suggestions  of  extreme  value." — Lancet. 

"  The  rapidity  with  which  this  book  has  reached  a  third  edition  shows  how  well  it 
has  been  appreciated  by  the  profession." — Practitione7\ 

"  It  will  always  be  a  book  of  reference   for  the  practitioner." — New  York  Medical 
youi'nal. 

"The  extensive  demand  for  a  really  good  treatise  on  the  subject  is  shown  by  the 
publication  of  the  third  edition  of  Dr.  Day's  work." — Edi7iburgh  Aledical  yottmal. 


THE 


DISEASES  OF  CHILDREN; 


FRiCTICiLAiHISIEMIlCffOM 


PRACTITIONERS  AND  STUDENTS. 


BY 

WILLIAM  HENRY  DAY,  M.D., 

AUTHOR  OF  headaches;  THEIR  CAUSE,  NATURE,  AND  TREATMENT, 

MEMBER  OF  THE  ROYAL  COLLEGE  OF  PHYSICIANS  OF  LONDON, 

PHYSICIAN  TO  THE  SAMARITAN  HOSPITAL  FOR  WOMEN  AND  CHILDREN. 


/ 

SECOND  EDITION. 

Rewritten  and  Much  Enlarged 


PHILADELPHIA: 

PRESLEY    BLAKISTON, 

No.   IOI2  Walnut  Street. 
I  88  I. 


'J^  33 


TO  MY  COLLEAGUES, 
THE  PHYSICIANS  AND  SURGEONS 

OF   THE 

SAMARITAN  HOSPITAL, 

S;^is  ffiork  is  §«bical£iJ, 

WITH 

EVERY  SENTIMENT  OF  RESPECT  AND  ESTEEM, 

BY 

THE  AUTHOR, 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/diseasesofchildrOOdayw 


PREFACE. 


This  volume  is  the  outcome  of  private  and  hospital  practice,  ex- 
tending over  a  lengthened  period.  My  aim  has  been  to  make  the 
work  useful,  and  to  rely  on  clinical  experience  rather  than  on 
theories ;  which,  even  when  proved,  cannot  always  be  brought  to 
bear  on  points  of  practical  interest. 

I  entertain  the  hope  that  the  following  pages  may  prove  useful 
both  to  the.  student  and  to  the  practitioner.  To  assist  the  student, 
I  have  classified  each  disease  and  its  varieties,  after  the  method 
sanctioned  by  modern  pathologists.  To  help  the  practitioner,  I 
have  carefully  placed  a  descriptive  heading  before  each  chapter,  to 
enable  him  to  obtain  readily  the  information  he  requires. 

In  arranging  the  list  of  prescriptions,  concentration  has  been  my 
aim.  Certain  broad  principles  are  kept  in  view,  as  regards  dose  and 
combination,  but  the  details  can  be  varied  at  the  discretion  of  the 
practitioner,  according  to  the  peculiarities  of  each  case  as  met  with 
in  practice.  I  have  invariably  prescribed  remedies  in  safe  doses. 
Some  medicines  will  be  taken  by  children  in  large  proportions  and 
a  cure  effected  when  small  doses  fail.  Thus  belladonna  may  cure 
incontinence  of  urine,  and  relieve  whooping-cough,  when  its  physi- 
ological effects  are  fully  produced.  Arsenic  will  cure  chorea  in 
large  doses,  whilst  it  will  frequently  fail  in  small  doses.  Opium  re- 
quires to  be  given  with  caution.  Calomel,  iron,  ipecacuanha,  and 
free  purgatives  are  well  borne  by  children,  while  strychnia  and 
prussic  acid  require  care  in  exhibition. 

I  have  to  thank  my  colleagues  at  the  Samaritan  Hospital  for  the 
opportunities  they  have  given  me  of  watching   interesting  cases 


Vlll  PREFACE. 

under  their  care,  and  of  giving  me  many  valuable  hints.  I  have 
especially  to  thank  Mr.  Alban  Doran  for  the  assistance  he  has  ren- 
dered me  in  the  chapters  on  Invagination  and  Intussusception,  and 
on  other  questions  of  surgical  interest. 

My  warmest  thanks  are  due  to  Dr.  Milner  Fothergill  for  much 
information  and  suggestion. 

I  have  laid  myself  under  great  obligation  to  the  writers  of  stand- 
ard works,  and  if  I  have  failed  anywhere  to  acknowledge  the  debt, 
the  omission  has  been  purely  accidental  and  unintentional. 

To  the  Transactions  of  the  Royal  Medical  and  Chirurgical  Society, 
of  the  Pathological  Society,  and  of  the  Clinical  Society,  as  well  as 
to  the  works  of  Jones  and  Sieveking  and  Wilks  and  Moxon,  I  am 
greatly  indebted. 

lo  Manchester  Square; 
April,  j88i. 


CONTENTS. 


CHAPTER  I. 

PAGE 

Introductory  Remarks, 17 


CHAPTER  II. 
Milk  Diet  and  Hygiene, 26 

CHAPTER  III. 
Acute  and  Chronic  Disease, 51 

CHAPTER  IV. 
Debility, 62 

CHAPTER  V. 
Dentition, 67 

CHAPTER  VL 
Marasmus  or  Atrophy, 73 

CHAPTER  VII. 
Fevers  of  Childhood, 7^ 


X  CONTENTS. 

CHAPTER  VIII. 

PAGE 

Typhoid  Fever, 83 

CHAPTER  IX. 
Special  Eruptive  Fevers, ...      97 

CHAPTER  X.  ^ 

MoRBiLLi  OR  Measles, loi 

CHAPTER  XL 
Scarlet  Fever  or  Scarlatina, 115 

CHAPTER  XII. 
Variola  or  Small-pox, 137 

CHAPTER  XIII. 
Diseases  of  the  Mouth  and  Fauces, 148 

CHAPTER  XIV. 
Indigestion, 164 

CHAPTER  XV. 

DiARRHCEA, 174 

CHAPTER  XVI. 
Gastritis-^Mel.^na — Dysentery, 194 

CHAPTER  XVII. 
Constipation  and  Colic, 200 


I  CONTENTS.  XI 

CHAPTER  XVIIL 

PAGE 

Intestinal  Obstruction, 207 

CHAPTER  XIX. 
Intussusception — Invagination, 210 

CHAPTER  XX. 
Diseases  of  the  Liver, 225 

CHAPTER  XXI. 
Icterus  or  Jaundice, 231 

CHAPTER  XXII. 

Painless  Enlargements  of  the  Liver, 237 

CHAPTER  XXIII. 
Diseases  of  the  Spleen, 242 

CHAPTER  XXIV. 
Diseases  of  the  Kidneys  and  Urinary  Organs, 248 

CHAPTER  XXIV  {Continued-). 
Diseases  of  the  Kidneys  and  Urinary  Organs, 264 

CHAPTER  XXIV  {Continued). 
Diseases  of  the  Kidneys  and  Urinary  Organs, 274 

CHAPTER  XXIV  {Continued). 
Diseases  of  the  Kidneys  and  Urinary  Organs, 287 


Xll  CONTENTS. 

CHAPTER  XXV. 
Diseases  of  the  Peritoneum, 294 


PAGE 


CHAPTER  XXVI. 
Ascites, 299 

CHAPTER  XXVII. 
Intestinal  Worms, ....         .    .         302 

CHAPTER  XXVIII. 
Diseases  of  the  Nasal  Cavities, 310 

CHAPTER  XXIX. 
Croup — Laryngo-tracheal  Diphtheria  of  some  Writers,      .     .     322 

CHAPTER  XXX. 
Diphtheria, 336 

CHAPTER  XXXI. 

Laryngismus  stridulus, •     •     357 

CHAPTER   XXXII. 
Pertussis  or  Whooping-cough, 366 

CHAPTER  XXXIII. 
Enlarged  Bronchial  and  Mediastinal  Glands, ^8^ 

CHAPTER  XXXIV. 
Asthma, 393 


CONTENTS.  Xlll 

CHAPTER  XXXV. 

PAGE 

Emphysema, 405 

CHAPTER  XXXVI. 
Bronchitis, 413 


CHAPTER  XXXVII. 
Pleurisy, 427 


CHAPTER  XXXVIII. 
Pneumonia, 448 

CHAPTER  XXXIX. 
Tuberculosis,     .    .    '. 472 

CHAPTER  XL. 
Phthisis  Pulmonalis  or  Pulmonary  Consumption, 500 

CHAPTER  XLI. 
Diseases  of  the  Heart,  . 529 

CHAPTER  XLII. 
Diseases  OF  THE  Brain, 557 

CHAPTER  XLIII. 
Epilepsy, 5S7 

CHAPTER  XLIV. 
Infantile  Convulsions  or  Eclampsia, 606 


XIV  '  CONTENTS. 


CHAPTER  XLIV  {^Continued). 


r±G^ 


Congestion  of  the  Brain, 6i8 

CHAPTER  XLV. 
Chorea  or  St.  Vitus's  Dance, 624 

CHAPTER  XLVI. 
Diseases  of  the  Spinal  Cord, 637 

CHAPTER  XLVII. 

Infantile  Paralysis — Acute  Anterior  Polio-myelitis,      .     .     .     647 

CHAPTER  XLVin. 
Rheumatism, 658 

CHAPTER  XLIX. 
Rickets  or  Rachitis, 669 

CHAPTER  L. 
Syphilis  in  Children, 684 

CHAPTER  LI. 
Anemia,     .     .     .     .     ; 692 

CHAPTER  LII. 
Diseases  of  the  Ear, 708 

CHAPTER  LIII. 
Diseases  of  the  Skin, ^. 716 


ERRATA  AND  ADDENDUM. 


On  page  365,  second  line  from  bottom,  for  "  Aquam  ad  Sj  "  read 
'' Aquam  ad  oiij."  ,  , 

On  page  379,  second  line  from  bottom,  for  "Aquam  ad"  read 
"aquse  aa." 

On  page  206,  at  bottom,  add  : 

Typhlitis  and  Perityphlitis.^ This  disease  consists  in  inflammation 
of  the  coats  of  the  csecum,  and  of  the  tissues  above  and  around  it.  It 
may  occur  without  apparent  cause,  or  follow  diarrhoea  or  constipation. 
Blows  on  the  abdomen,  exposure  to  damp  and  cold,  impacted  faeces,  or 
foreign  bodies  in  the  caecum  may  induce  it. 

The  symptoms  are  pain  and  tenderness  over  the  right  iliac  fossa, 
colicky  pains  in  the  abdomen,  vomiting,  constipation  or  diarrhoea,  and 
febrile  disturbance.  The  patient  lies  on  his  back,  or  right  side,  with 
his  legs  drawn  up  to  relax  the  abdominal  muscles. 

The  prognosis  is  generally  favorable  unless  the  disease  leads  to  per- 
foration of  the  csecum  and  peritonitis.  If  abscess  form,  it  may  open 
into  the  bowel  or  externally  through  the  abdominal  wall,  the  chance 
of  recovery  being  greater  in  the  former  than  in  the  latter. 

The  diagnosis  consists  in  sudden  localized  pain  and  tenderness  in 
the  right  iliac  fossa,  with  more  or  less  swelling,  vomiting,  and  con- 
stipation. It  may  be  mistaken  for  hip-disease*  or  ovaritis  in  young 
girls  who  have  begun  to  menstruate,  or  to  the  passage  of  a  renal 
calculus,  t 

Treatment. — If  pain  and  tenderness  are  acute,  it  will  be  advisable 
to  apply  three  or  four  leeches  over  the  csecum,  followed  by  warm  and 
light  poultices.  Opium  to  relieve  pain  in  small  doses  by  the  mouth, 
or  what  is  preferable,  a  few  drops  of  laudanum  thrown  into  the 
rectum.  When  the  pain  is  relieved,  enemata  may  be  used,  or  even  a 
mild  laxative,  if  there  is  no  vomiting,  but  the  greatest  care  is  necessary 
in  the  use  of  aperients. 

*  Perityphlitis  in  Children,  The  American  Journal  of  the  Medical  Sciences,  by 
V.  P.  Gibney,  M.D.,  1881,  p.  119. 
t  See  Chap.  XXIV,  p.  275. 


DISEASES  OF  CHILDREN. 


CHAPTER    I. 


INTRODUCTORY   REMARKS. 


The  study  of  children's  diseases — Their  special  characters  and  peculiarities — Manarjement 
during  growth  and  development — Importance  of  attending  to  the  constitutional  rather 
than  to  the  local  state — Constitutional  and  hereditary  disease. 

The  diseases  of  clnldren  have  a  claim  to  be  considered  separately 
and  specially.  It  is  before  mental  training  has  worked  its  influ- 
ence, and  the  body  has  undergone  the  wear  and  tear  of  adult  life, 
that  we  are  able  to  study  disease  in  its  most  natural  form.  An 
opportunity  is  presented  to  us  of  seeing  disease,  as  it  were,  unre- 
strained and  free,  running  its  course  in  a  tender  frame,  keenly 
sensitive  to  exaltation  and  depression,  without  the  complications 
and  the  thousand  collateral  circumstances  which  determine  the 
form  and  character  of  the  disease  which  is  to  assail  it  in  subse- 
quent life.  All  practitioners  of  medicine  will  admit  that  the  dis- 
eases of  children  should  be  regarded  in  a  distinct  light  from  like 
diseases  of  adults,  where  too  frequently  disease  acts  upon  shattered 
organs  and  worn-out  tissues.  The  remarkable  peculiarities  which 
disease  assumes  in  children,  the  course  it  follows,  and  the  rapid 
transition  from  a  state  of  danger  to  recovery,  make  this  study 
very  important. 

Often  obscure  and  difficult  of  detection,  these  diseases  quickly 
attain  force  and  intensity,  and  run  on  uncontrolled  by  any  measures 
within  our  reach.  It  may  be  they  have  slumbered  for  a  variable 
time  in  the  system,  occasioning  little,  if  any  disturbance  to  the 
general  health  that  could  be  looked  upon  as  positively  foreboding 
evil  to  come;  or  it  may  be,  from  causes  not  readily  discoverable, 

2 


18  DISEASES   OF   CHILDEElSr. 

tliej  have  a  sudden  and  fierce  origin.  iJ^ow  and  then,  after  lasting 
weeks  and  months  together,  defying  medicine  and  the  highest 
medical  skill,  they  take  a  turn  in  the  right  direction.  Each  stage 
of  them  is  characterized  by  graver  symptoms  till  a  turning-point 
is  reached,  and  then  convalescence  sets  in  slowly  and  steadily. 

A  life  of  physical  activity  when  the  renovation  of  the  tissues 
is  most  vigorously  proceeding  makes  great  calls  on  the  digestive 
functions,  and  these  again,  for  the  maintenance  of  their  integrity, 
depend  on  sleep  and  repose  when  weariness  sets  in.  Excessive 
mental  exertion  interferes  with  the  growth  of  the  body.  The  two 
cannot  be  actively  carried  on  with  impunity  at  the  same  time ;  the 
one  is  peculiar  to  childhood,  the  other  comes  naturally  with  the 
approach  of  maturity,  and  increases  with  the  love  of  sedentary 
habits.  When  the  organic  processes  are  most  active  they  are  most 
easily  upset,  or  hindered  in  their  course,  and  in  this  respect  alone 
they  differ  as  much  from  similar  functions  in  the  adult  as  a  thriving 
shrub  does  from  a  full-grown  tree. 

The  children  of  the  present  day  are  reared  differently,  taught 
differently,  and  fed  differently  from  those  of  half  a  century  ago, 
and,  as  a  consequence,  the  power  of  disease  is  greatly  modified  by 
such  changes.  These  are  very  important  considerations,  and  must 
be  borne  in  mind  if  we  would  successfully  lay  smooth  this  uneven 
field  of  medical  inquiry,  for  I  think  fault  maj^  often  be  ascribed  to 
us  in  not  adequately  estimating  the  diflerence  of  power  between 
similar  diseases  in  the  young  child  and  the  adult.  It  is  necessary, 
then,  that  the  diseases  of  early  life  receive  a  most  attentive  con- 
sideration, for  if  overlooked,  or  ill  understood,  the  seeds  of  mis- 
chief are  allowed  to  take  deep  root,  and  a  degenerate  maturity  is 
encouraged.  A  large  number  of  the  children  of  the  poor  in  Lon- 
don grow  up  to  be  tuberculous,  and  ultimately  die  of  pulmonary 
phthisis,  from  disregard  of  their  early  illnesses  on  the  part  of  their 
parents.  Small  children,  imperfectly  recovered  from  the  eruptive 
.  fevers,  are  allowed  to  run  about  in  the  streets  almost  before  the 
rash  has  disappeared;  and  the  lung  affection,  which  so  constantly 
attends  measles,  is  permitted  to  go  on  without  any  treatment  at 
all.  Suppurating  cervical  glands,  otorrhoea  ending  in  cerebral  dis- 
ease, dropsy,  ophthalmia,  etc.,  all  follow  in  the  rear  of  neglect  and 
starvation.  The  functions  of  childhood  are  remarkable  for  change, 
development,  and  activity;  the  skin  is  sensitive  to  all  external  in- 
fluences, diarrhcea  and  vomiting  are  easily  provoked,  and  the  ner- 


INTRODUCTORY  REMARKS.  19 

vous  system  is  very  impressible.  Ilence  an  amount  of  cold  or  heat 
which  would  uot  affect  a  grown-up  person  would  be  fatal  to  a 
young  child,  for  in  proportion  to  the  rapid  changes  which  are 
going  on  there  is  a  proportionate  degree  of  risk.  It  is  no  easy 
task  to  adjust  the  balance  and  to  keep  it  steadily  equipoised. 
Disorder  in  one  part  is  enough  to  disturb  the  whole  machinery, 
and  slight  mischief  having  been  set  up  in  an  unimportant  part 
may  rapidly  extend  its  influence  to  another  distant  and  vital 
part. 

We  have  much  to  learn  then,  during  the  period  of  growth, 
change,  and  development.  In  a  great  measure  children  must  be 
managed  according  to  the  strength  with  which  they  enter  into  the 
world.  Some  are  born  weak  and  fragile,  and  require  the  most 
delicate  attentions  to  rear  them  through  this  stage.  If  the  same 
measures  are  adopted  as  with  stronger  children  they  would  either 
die,  or  grow  up  miserably  wretched  or  unhealthy.  Ko  astonish- 
ment can  be  awakened  at  this  if  we  consider  for  a  moment  the  life 
many  mothers  lead  during  the  trying  period  of  pregnancy.  Late 
hours  lead  to  fatigue,  to  excitement,  and  to  stimulating  and  im- 
proper diet,  which  are  sure  means  of  causing  them  to  bear  an 
unhealthy  offspring.  In  London  and  other  large  cities  these  re- 
marks are  especially  applicable.  The  calm  quiet  of  country  life, 
with  regular  and  abstemious  habits,  alone  conduces  to  a  natural 
and  tranquil  state  of  mind  and  body.  All  this  leads  to  sound  and 
vigorous  health  in  the  mother,  and  as  surely  to  health  in  the  chil- 
dren she  bears. 

M}^  colleague.  Dr.  Percy  Boulton,  has  devoted  much  time  and  x 
attention  to  the  subject  of  physical  development  in  children.  AYhat 
Professor  Bowditch,  of  Boston,  has  done  for  Americans,  Quetelet 
fur  Belgians,  and  Charles  Eoberts  for  English  factory  children.  Dr. 
Boulton  has  done  for  well-to-do  English  children.  The  physical 
averages  of  factory  children  are  as  poor  a  standard  of  measurement 
as  their  mental  averages  are  a  criterion  of  brain  capacity.  It 
seems  unnecessary  to  explain  that  syphilis,  struma,  and  drink  on 
the  one  hand ;  bad  food,  clothing,  housing,  and  premature  exces- 
sive bodily  labor  on  the  other ;  tend  to  stunt  the  growth  of  the 
working  classes.  An  average  of  the  weight  and  height  of  factory 
children  is  no  standard  for  those  more  favorably  situated  in  life. 

Dr.  Boulton  has  arrived  at  the  following  very  valuable  conclu- 
sions : 


20 


DISEASES   OF   CHIEDEEN". 


"  Health}'  childreu  grow  at  the  following  rate  per  annum — 

Slow  growing, 2    inches  a  year 

Average, 2^      "         " 

Fast  growing, 3        "         " 

A  child  that  grows  2  inches  a  year  will  be  a  short  adult,  2|  inches 
a  medium,  and  3  inches  a  tall  adult.  Weight  should  increase 
regularly  with  height,  and  there  is  no  more  certain  forerunner  of 
disease  or  unhealthy  development  than  discrepancy  in  the  weight 
for  height  ratio.  Growth  should  proceed  regularly  and  evenly,  not 
by  fits  and  starts.  Delicate  children  grow  most  irregularly.  Illness 
in  a  great  measure  checks  their  development,  during  which  time 
they  lose  ground  that  either  is  never  made  up,  or  only  by  a  bound 
which  sadly  taxes  the  strength."* 

It  is  most  important  that  we  should  have  some  standard  to  go 
by,  and  this  is  supplied  us  in  the  table  of  averages  which  Dr. 
Boulton  has  drawn  up  as  the  result  of  very  numerous  observations 
of  his  own  amongst  the  children  of  healthy  well-to-do  people.  He 
particularly  mentions  that  his  endeavor  has  been  to  exclude  all 
dwarfs,  giants,  and  evidently  diseased  and  unhealthy  children, 
which  so  seriousl}''  alter  the  averages  of  other  observers,  and  be- 
lieves that  he  has  thas  prepared  a  scale  which  may  be  regarded  as 
a  standard  for  children  brought  up  under  favorable  conditions. 

Table  of  Averages. 


Height. 

Wei 

ght. 

Height. 

Weight. 

Feet. 

Inches. 

Stone. 

lbs. 

Feet. 

Inches. 

Stone. 

lbs. 

3 

0 

2 

8 

4 

1 

4 

6^ 

3 

1 

2 

10 

4 

2 

4 

9 

3 

2 

2 

12 

4 

3 

4 

m 

3 

3 

3 

0 

4 

4 

5 

0 

3 

4 

3 

2 

4 

5 

5 

•)1 
-2" 

3 

5 

3 

4 

4 

6 

5 

5 

3 

6 

3 

6 

4 

7 

5 

7^ 

3 

7 

3 

8 

4 

8 

6 

10 

3 

8 

3 

10 

4 

9 

5 

121 

3 

9 

3 

12 

4 

10 

6 

1 

3 

10 

4 

0 

4 

11 

6 

3^- 

3 

11 

4 

2 

5 

0 

6 

6 

4 

0 

4 

4 

*  Some  Anthropometrical  Observations,  liarveian  Society,  March,  1880. 


INTRODUCTORY   REMARKS.  21 

The  first  year  of  infant  life  is  especially  perilous  from  defective 
nutrition  and  want  of  proper  care.*  We  are  assured  of  this  from 
the  fact  that  the  mortalities  so  much  greater  among  the  children 
of  the  poor  than  among  those  of  the  rich  ;  in  the  manufacturing 
districts  of  the  north,  and  in  overcrowded  dwellings,  than  in  rural 
districts,  where  the  mothers  go  to  field  work,  and  where  three  or 
four  families  are  not  compelled  to  reside  in  one  small  house.  It  is 
a  mystery  that  children  can  be  reared  at  all  in  some  of  our  great 
cities  and  towns,  on  account  of  the  impurity  of  the  air  they 
breathe,  and  the  insanitary  condition  of  the  hovels  they  inhabit. 
Better  accommodation  must  be  provided  for  the  poor  if  we  would 
lessen  the  waste  of  infant  life  and  the  spread  of  zymotic  diseases — 
a  spread  accelerated,  no  doubt,  in  these  days  by  the  rapid  inter- 
course between  one  country  and  another. 

Those  accustomed  to  children  will  observe  signs  and  s^T-mptoms 
about  them  of  great  weight  and  significance,  which  would  pass  un- 
noticed by  others  not  possessing  this  experience.  They  detect  the 
coming  storm,  and  avert  it  by  simple  and  appropriate  treatment ; 
and  so  a  formidable  disease  may  sometimes  be  annihilated  by  good 
judgment  and  forethought.  There  are  few  diseases  occurring  in 
later  life  that  require  so  much  sagacity  to  detect  as  the  various 
disorders  and  ailments  of  young  children,  or  so  much  discrimination, 
tact,  and  judgment  in  the  successful  management  of  them.  I 
have  elsewhere  stated  that  constitutional  symptoms  always  demand 
a  large  share  of  attention,  and  that  we  have  often  erred  when  we 
have  trusted  too  exclusively  to  physical  and  local  signs.  At  all 
ages  and  in  both  sexes,  it  is  my  belief  that  we  are  never  likely  to 
be  so  successful  in  controlling  disease  as  when  we  mainly  direct  our 
treatment  to  the  constitutional  state.f  This  does  not  imply  care- 
lessness of,  or  indifference  to,  physical  signs.  In  children  the  con- 
stitutional state  should  never  be  forgotten,  for  many  a  sound 
practitioner  has  lost  his  little  patient,  whilst  watching  the  pulse 

*  It  is  stated  on  the  authority  of  M.  Kuborn,  of  Belgium,  that  the  mortality  for  this 
period  of  life  in  the  principal  countries  of  Europe  is  as  follows :  "  Out  of  1000  children, 
there  die  in  Sweden  153,  in  Denmark  136,  in  Scotland  156,  in  England  170,  in  Bel- 
gium 186,  in  Holland  211,  in  France  216,  in  Prussia  220,  in  Spain  226,  in  Switzerland 
252,  in  Italy  254,  in  Austria  303,  in  Russia  311,  and  in  Bavaria  372." — British  Medical 
Journal,  January  27th,  1877,  p.  113. 

t  Vide  a  paper  by  the  author  On  the  Relative  Value  of  Symptoms  in  the  Diag- 
nosis and  Treatilient  of  Disease.  Transactions  of  the  St.  And.  Med.  Grad.  Associa- 
tion, vol.  ii,  p.  78,  1869. 


22  DISEASES   OF  CHILDREN. 

closely  and  listening  with  care  to  the  respiration,  when  he  might 
have  saved  life  by  leaving  these  symptoms  to  take  care  of  them- 
selves and  looking  to  the  general  state  as  the  sure  index  of  danger. 
Neither  the  pulse,  the  skin,  nor  any  light  which  auscultation  and 
percussion  afford,  are  such  valuable  signs  of  disease  in  children  as 
they  are  in  adults.  Constitutional  diseases  are  the  consequences  of 
impairment  in  the  processes  of  nutrition  and  secretion.  In  children 
they  are  more  frequently  hereditary  than  acquired.  A  child  is 
born  with  a  predisposition  to  some  particular  disease,  as  tubercle, 
cancer,  gout,  etc. ;  but  if  the  life  it  leads  is  conducive  to  sound 
health,  the  morbid  tendency  may  never  show  itself.  And  this 
may  afford  an  explanation  of  a  constitutional  and  hereditary  disease 
skipping  one  generation  and  appearing  in  the  next.* 

"When  the  general  and  constitutional  signs  of  disease  are  well 
established,  they  are  sometimes  cut  short  with  the  same  sudden- 
ness with  which  they  attained  their  severity.  But  when  the  phys- 
ical signs  of  disease  are  also  well  developed,  as  in  some  cases  of 
continued  fever,  bronchitis,  and  pneumonia,  our  prognosis  becomes 
far  more  serious,  and  a  tendency  to  sudden  prostration,  and  even 
fatal  collapse  may  steal  on  in  a  few  hours. 

*  "The  health  of  an  individual  depends  not  merely  upon  existing,  but  also  on  ante- 
cedent causes.  Part  of  his  health  is  transmitted  from  his  ancestors,  and  may  be  a  mere 
survival  of  hygienic  conditions  which  have  been  extirpated.  Part  of  our  health  also 
depends  upon  the  external  conditions  of  our  upbringing  when  young,  and  part  also  on 
the  influence,  physical  and  moral,  to  which  we  are  exposed  all  through  our  lives.  As 
there  is  no  individual  who  can  be  said  to  have  all  his  organic  functions  in  the  most 
perfect  action,  so  there  is  no  community  that  can  be  considered  in  a  perfectly  healthy 
state,  for  the  general  health  depends  upon  all  the  movements  of  the  private  health  of 
the  individuals.  The  health  of  a  nation,  physiologically  considered,  stands  closely  in 
relation  to  that  of  an  individual.  The  nutrition  and  health  of  an  individual  depend 
upon  the  well-adjusted  balance  of  the  supply  and  waste  of  the  particles  which  compose 
the  body.  These  particles  of  the  body,  all  through  the  life  of  man,  are  incessantly 
dying,  and  are  being  replaced  by  new  particles  continually  springing  into  life.  Every 
organ  is  tluis  undergoing,  through  its  particles,  a  continued  and  rapid  alternation  of 
death  and  life.  As  the  whole  body  is  to  one  of  these  particles  so  is  the  whole  body 
politic  of  a  nation  to  the  individuals  of  which  it  is  composed.  The  death  of  an  indi- 
vidual in  a  state  is  strictly  analogous  to  the  death  of  a  particle  in  a  single  man,  and 
the  birth  of  an  individual  in  a  state  is  the  analogue  of  the  moulding  of  a  new  living 
particle  into  tlie  body  of  a  man.  Wiien  an  individual  becomes  diseased,  there  is  some 
want  of  balance  between  the  waste  and  supply  of  his  organs — or  rather  of  the  underly- 
ing protoplasm  wiiich  is  incessantly  changing  from  life  to  death.  When  the  waste  of 
the  ultimate  particles  is  greater  than  the  power  of  restoration,  disease  attacks  the  indi- 
vidual."— Address  of  Dr.  Lyon  Playfair,  On  Sanitary  Reform,  delivered  before  the 
Social  Science  Congress  at  Glasgow,  October  3d,  1874. 


INTRODUCTORY   REMARKS.  23 

"We  cannot,  in  many  complaints,  so  easily  determine  the  extent 
and  degree  of  local  mischief  in  children  as  we  can  in  adults ;  and 
even  where  we  are  pretty  certain,  we  shall  find  it  an  admirable  rule 
to  trust  to  the  general  condition  of  these  young  patients,  rather 
than  to  rely  on  the  uncertain  knowledge  which  doubtful  local  signs 
often  create  in  our  minds.  It  is  often  quite  impossible  to  depend 
upon  the  testimony  of  children  as  to  the  seat  of  pain  or  suffering, 
and  the  medical  attendant  requires  to  exercise  very  great  dis- 
cretion and  judgment  before  he  draws  any  conclusion.  Let  the 
abdomen  of  a  child  be  lightly  pressed,  and  it  will  almost  always, 
when  interrogated,  reply  that  it  feels  pain.  Even  the  testimony  of 
adults  under  such  an  examination  may  mislead  us.  In  a  case  of 
fever  it  may  be  very  important  to  be  safe  on  this  point,  as  I  am 
satisfied  I  have  seen  leeches  and  counter-irritants  applied  when  the 
local  signs  of  pain  or  congestion,  or  inflammation  have  not  existed.* 
The  tumid  and  protuberant  abdomen  of  a  child  is  sometimes  looked 
upon  as  an  indication  of  disease,  when  it  is  in  all  respects  healthy 
and  natural.  The  contrast  between  the  abdomen  of  a  child  and 
that  of  an  adult  is  too  well  known  to  need  comment  here. 

Now,  there  are  a  few  points  respecting  the  management  of  chil- 
dren in  health  which  if  known  are  not  acted  upon,  and  the  neglect 
of  them  is  followed  by  serious  after-consequences.  Health  is 
dependent  in  large  measure  upon  points  which  may  appear  very 
trifling,  but  which  nevertheless  if  overlooked,  from  their  apparent 
insignificance,  may  grow  into  open  dangers. 

Disease  is  early  and  easily  implanted  by  the  parents  of  children 
who  set  at  defiance  those  natural  laws  upon  the  observance  of  which 
health  and  strength  depend.  A  young  child,  like  a  young  plant, 
requires  suitable  nourishment  and  judicious  feeiling,  and  without 
in  any  way  pandering  to  every  fancied  ailment,  I  would  urge  a 

*  In  the  early  part  of  my  professional  career  I  remember  an  old  physician  making 
pressure  over  the  right  iliac  region  of  a  fever  patient  whom  he  saw  in  consultation  with 
me,  and  insisted  that  some  lesion  of  the  intestine  was  either  present  or  threatening. 
The  patient  admitted  that  pressure  hurt  her,  and  accordingly  the  linimentum  hydrar- 
gyri  was  ordered  to  be  rubbed  in  night  and  morning  over  the  supposed  seat  of  mischief, 
and  small  doses  of  mercury  and  Dover's  powder  given  by  the  mouth.  I  soon  desisted 
from  the  use  of  mercury,  but  not  before  it  had  produced  slight  ptyalism.  The  progress 
of  the  case  justified  the  opinion  that  the  intestines  had  escaped  the  lesion  to  which 
they  are  so  liable.  I  give  this  case  in  point,  because  delicacy  of  touch,  the  position  of 
the  patient  when  under  examination,  the  weighing  evidence  from  a  set  of  symptoms 
rather  than  from  one,  are  so  essential  in  the  diagnosis  and  treatment  of  disease. 


24  DISEASES   OF    CHILDREN. 

constant  scrutiny  and  watclifulness.  Those  children  are  the 
healthiest  and  strongest  in  every  way  who  are  allowed  certain  free- 
dom in  their  amusements  and  outdoor  exercises.  The  overfond 
and  timid  parent  shuts  up  her  child  in  one  temperature  to  protect 
him  from  cold  and  damp,  and  this  often  to  the  ruin  of  his  general 
health,  because  it  is  impossible  to  provide  against  the  variability 
of  temperature  in  this  climate.  Very  young  children  should  be 
kept  warm,  and  yet  not  strangled  with  tight  clothing.  Plenty  of 
pure  air  is  most  essential  for  health.  "When  the  weather  is  fine, 
they  ought  to  be  sent  out  in  the  air  every  day,  and  the  windows  of 
their  nurseries  and  sleeping-rooms  should  be  opened  twice  daily. 
In  a  climate  like  that  of  England,  however,  where  we  have  seldom 
two  days  alike,  great  prudence  is  required  before  exposing  children 
to  any  risk  of  cold,  as  the  respiratory  tract  is  so  sensitive  in  early 
life.  Cold  alone  will  originate  other  evils;  the  mucous  membrane 
of  the  stomach  and  bowels  will  also  suffer,  and  delicate  health 
becomes  established,  from  which  the  child  either  sinks,  or  very 
slowly  recovers.  When  infants  are  taken  out  of  doors  a  nurse's 
arms  are  preferable  to  a  perambulator,  on  account  of  the  warmth 
she  imparts  to  them. 

If  we  consider  the  way  in  which  the  children  of  the  poor  are 
brouo-ht  up  in  the  country,  we  may  learn  a  lesson  from  it.  When 
born  of  healthy  parents,  they  endure  with  impunity  the  trying 
changes  of  our  climate,  and  resist  diseases  to  which  their  poorer 
brethren  in  large  towns  and  overcrowded  dwellings  would  quickly 
succumb.*  In  the  middle  and  upper  ranks  of  life  children  are 
often  injudiciously  fed  ;  their  meals  are  increased  in  richness  and 
frequency,  when  they  should  be  of  the  plainest  kind  and  moderate 
in  quantity.  When  a  child  refuses  food,  my  maxim  is  always  to 
let  it  alone  for  a  time.  The  appetite  of  a  child  is  a  good  gauge  of 
its  powers  of  digestion,  and  if  you  force  it  to  eat  against  its  will 
the  probabilities  are  that  the  food  will  disagree.  In  such  cases  the 
rule  we  ought  to  lay  down  for  eating  should  be,  "little  and  seldom," 
and  not  "  little  and  often."     The  digestive  organs  require  rest  in 


*  "Given  tlie  benefits  of  an  outdoor  life  in  a  pure  atmosphere,  and  tlie  child  of  the 
country  peasant  will  tlirive,  and  develop  an  abundance  of  blood  and  muscle,  almost 
without  meat  at  all.  The  children  of  the  poorer  classes  in  towns  stand  upon  a  very- 
different  footing,  and  the  struma  and  other  diseases  fostered  in  close  alleys  are  often 
greatly  aggravated  by  the  effects  of  an  insulBcient  diet."— T^e  Lancet.  Editoi-'s  Re- 
marks, April  20th,  1872,  p.  550. 


INTEODUCTORY   REMARKS.  25 

common  with  the  brain  and  the  organs  of  locomotion  ;  and  yet  as 
soon  as  derangement  of  them  sets  in,  the  habit  is  too  frequently 
followed  of  administering  food  and  medicine,  by  which  they  are 
kept  in  a  perpetual  state  of  irritation.  Some  time  ago  I  was  called 
to  see  a  young  child  in  the  country,  whose  friends  were  alarmed 
because  of  a  refusal  to  swallow  food.  The  pulse  and  temperature 
were  normal,  there  was  neither  pain,  headache,  nor  diarrhoea.  In 
the  absence  of  any  tangible  symptoms  I  suggested  to  the  medical 
man  in  attendance  that  he  might  be  content  to  leave  the  case  alone. 
In  a  day  or  two  the  appetite  returned,  and  the  child  recovered 
her  usual  spirits  without  the  aid  of  medicine. 

Unless  marked  indications  exist,  I  entirely  disapprove  of  the 
pernicious  practice  of  flying  to  tonics,  alteratives,  and  aperients, 
as  the  case  may  be.  Let  the  food  be  wholesome  and  nutritious, 
or  the  worst  state  of  health  may  be  engendered ;  but  medicines 
are  foreign  to  the  system,  and  should  be  avoided  when  possible,  it 
being  far  better  to  trust  to  food  than  to  physic.  Convulsions, 
marasmus,  abdominal  and  thoracic  affections,  are  constantly  to  be 
ascribed  to  improper  and  insufficient  food. 

Parents  and  nurses  seem  unmindful  of  the  necessity  for  adapt- 
ing the  diet  to  the  age  and  strength  of  the  child,  by  which  they 
cause  much  unnecessary  suffering,  and  frequently  invite  disease: 
Indigestion,  that  prevalent  source  of  subsequent  evil,  is  brought 
about  in  a  great  many  cases  by  feeding  young  children  with  fari- 
naceous food  and  different  kinds  of  biscuits,  which  undergo  fer- 
mentation, and  produce  distressing  flatulence  and  disorder  of  the' 
stomach  and  bowels.  Such  diet,  in  the  absence  of  milk,  is  obvi- 
ously unfit  for  the  purpose  of  growth  and  nutrition,  indigestion 
sets  in,  and  the  child's  hunger  seems  never  appeased  ;  the  liver  is 
said  not  to  act,  medicine  is  given,  and  there  is  an  aggravation  of 
the  evil.  It  loses  flesh,  and  is  crying  and  whining  during  the  day, 
till  the  bowels  start  off,  producing  temporary  ease.  There  is  the 
same  restlessness  and  discomfort  at  night.  The  extremities  be- 
come wasted,  and  the  skin  hangs  in  loose  folds  ;  the  bowels  are 
irregular,  and  the  stools  are  vitiated  ;  sometimes  there  is  consti- 
pation, and  sometimes  diarrhoea,  and  many  children  succumb  be- 
fore they  reach  the  age  of  one  year,  owing  in  a  great  many  caseg 
to  the  manner  in  which  they  are  fed.  Each  woman  has  her  own 
method  of  feeding  her  child,  and  it  cannot  be  denied  that  some 
children  grow  up,  and  thrive  even,  under  any  system  that  .the 
fancy  or  caprice  of  the  mother  may  dictate. 


26  DISEASES  OF  CHILDREN. 


CHAPTER   II. 

MILK   DIET    AND    HYGIENE. 

Composition  of  milk — Condensed  milk,  its  properties  and  value — Use  of  milk  in  disease  and 
constitutional  weakness — Farinaceous  foods — Dentition — Choice  of  a  nurse — Constipa- 
tion— Scotch  oatmeal — Stimulants — Air,  exercise  and  sleep — Cold  bathing — Aperient 
m.edicines,  their  uses  and  abuses — Preparations  of  iron — Antimony — Sedatives — Opium 
— Bromide  of  potassium — Hydrate  of  chloral — General  conclusions. 

Milk  contains  all  the  necessary  ingredients  for  the  preservation 
of  health,  and  at  no  period  of  life  is  it  so  valuable  as  during  that 
of  growth,  when  the  functions  of  assimilation  and  digestion  are 
most  active.  The  rapid  increase  of  growth  in  all  the  tissues,  and 
the  waste  that  also  hourly  goes  on,  demand  that  nourishment 
should  be  supplied  at  short  intervals.  "We  thus  introduce  into 
the  stomach  a  fluid  which  does  not  tax  the  tender  membrane  in 
its  work  of  absorption,  and  rare  are  the  instances  in  which  it  is 
not  tolerated. 

The  composition  of  milk  is  variable  both  in  quantity  and  qual- 
ity, according  to  the  animal  which  furnishes  it  and  the  state  of 
that  animal's  health  at  the  time.  It  varies  according  to  the 
amount  and  quality  of  the  food,  the  time  at  which  it  is  drawn, 
and  a  number  of  other  circumstances.  For  instance,  pasture-fed 
cows  yield  an  alkaline  milk,  whereas  the  milk  of  the  stall-fed  is 
more  or  less  acid,  and  therefore  less  digestible  for  infants.  The 
principal  ingredients  in  milk  are  casein,  sugar,  fat,  and  salts.  So 
long  as  the  carnivora  live  on  a  purely  animal  diet  no  sugar  can  be 
detected  in  the  milk,  but  when  the  diet  is  mixed,  as  it  is  in  the 
human  species  and  amongst  difterent  herbivorous  animals,  sugar 
rappears,  and  all  the  different  ingredients  undergo  great  variation. 

Woman's  milk  is  rich  in  milk-sugar  and  fat,  but  poor  in  casein.* 

*  "La  Presse  Medicale  says  that  the  researches  of  Dr.  Condereau,  of  Paris,  show 
;that  the  milk  of  Esquimaux  women  contains  a  small  proportion  of  salts,  but  is  rich  in 
sugar,  and  especially  in  fat,  derived  from  the  great  amount  of  oily  food  which  they 
consume  to  resist  the  cold  in  their  native  land." — Medical  Press  and  Circular,  Febru- 
ary a3th,  1878,  p.  142. 


MILK    DIET    AXD    HYGIEXE.  27 

Mare's  milk  is  poor  in  casein  and  fat,  but  extremely  rich  in  milk- 
sugar.  Ass's  milk  contains  a  much  larger  quantity  of  milk-sugar 
and  salts  than  that  of  woman's,  but  more  water  and  less  casein 
and  butter.  Yernois  and  Becquerel  estimate  the  casein  of  ass's 
milk  at  35.65  per  1000,  and  the  butter  at  18.50  ;  the  casein  in 
human  milk  at  39.24,  and  the  butter  at  34.61.  After  mare's  milk, 
sheep's  milk  contains  the  most  solids,  then  cow's,  then  goat's,  then 
woman's.  According  to  some  authorities  the  casein  is  a  combi- 
nation of  albumen  and  potash.  The  great  difference  between 
albumen  and  casein  consists  in  this,  that  the  latter  is  not  coagu- 
lated by  heat,  which  precipitates  the  former.  Casein  is  coagulated 
by  acetic  acid,  which  is  not  the  case  with  albumen.  Casein  seems 
to  have  also  the  power  of  combining  with  the  phosphates  of  lime 
and  magnesia,  and  rendering  them  soluble.  The  saline  matter  of 
milk,  which  is  nearly  the  same  as  that  of  the  blood,  is  largest  in 
cow's  and  goat's  milk;  it  seldom  exceeds  one  per  cent.,  and  in 
poor  milk  it  may  be  considerably  lower.  Cows  fed  on  beet-root 
and  carrot  augment  the  sugar  ;  the  race  of  Alderneys  are  said  to 
give  more  fat,  and  the  long-horns  more  casein. 

In  the'  milk  of  the  cow,  goat,  and  sheep,  the  proportions  of 
casein,  butter,  and  sugar,  are  nearly  the  same,  varying  from  three 
to  five  per  cent.  Milk,  then,  contains  three  classes  of  organic  con- 
stituents ;  the  albuminous,  the  saccharine,  and  the  oleaginous, 
with  those  mineral  ingredients  so  necessary  for  the  consolidation 
and  development  of  the  infant  fabric.  In  the  human  female  the 
saccharine  and  oleaginous  elements  are  present  in  large  amount, 
but  they  are  affected  by  the  kind  of  food  which  is  taken  and  the 
amount  of  outdoor  exercise.  Exercise  is  said  to  favor  the  secre- 
tion of  casein,  and  the  cattle  which  feed  in  exposed  situations, 
and  have  to  take  great  muscular  exercise  to  procure  their  food,  as 
m  Switzerland  and  some  other  mountainous  and  barren  districts, 
yield  only  a  small  quantity  of  butter,  but  a  larger  proportion  of 
cheese.  The  very  opposite  takes  place,  according  to  Carpenter, 
when  the  same  cattle  are  stall-fed. 

Unless  milk  is  perfectly  fresh  and  reliable,  it  is  very  prone  to 
undergo  lactic  acid  fermentation,  and  thus,  in  becoming  sour,  a 
fungoid  growth  is  developed  which  is  highly  detrimental  to  infan- 
tile assimilation.  The  milk  so  changed  might  not  try  the  strong 
digestive  powers  of  an  adult,  but  for  an  infant  or  young  child  it 
would  lay  the  foundation  of  delicacy,  and  invite  those  diseases 


28  DISEASES    OF    CHILDREN. 

which  are  so  ready  to  attack  early  life.  We  are  too  well  ac- 
quainted with  the  cramp,  spasm,  and  indigestion,  which  attack 
children  who  are  brought  up  by  hand,  and  who  take  their  milk 
out  of  dirty  bottles.  The  casein  undergoes  decomposition,  and 
lactic  acid  is  formed  in  large  quantities. 

Pure  cow's  milk  should,  when  placed  in  a  tall  narrow  glass  ves- 
sel, be  opaque,  and  of  a  perfectly  white  color,  having  no  deposit, 
and  without  any  peculiar  smell  or  taste.  Boiling  should  not 
change  its  appearance.  It  ought  to  yield  from  six  to  twelve  per 
cent,  of  cream  by  volume.  This  is  hastened  by  adding  water,  and 
the  cream  should  rise  in  from  four  to  six  hours.  Its  specific 
gravity  varies  from  1.026  to  1.035.  Some  authorities  give  from 
1.028  to  1.032,  and  say  that  if  it  falls  below  1.026  it  indicates  that 
the  milk  is  poor,  or  that  water  has  been  added.  The  specific 
gravity  is  therefore  a  most  important  test  of  the  quality  of  milk. 
But  it  must  be  remembered  that  a  large  quantity  of  cream  will 
lower  the  specific  gravity,  which  rises  again  when  the  cream  is 
removed.  Dr.  Parkes  says,  "  The  average  specific  gravity  of  un- 
skimmed rnilk  may  be  taken  as  at  1.030  at  60°  Fahr.,  and  the 
range  is  nearly  4°  above  and  below  the  mean." 

In  the  adulteration  of  milk,  water  is  most  commonly  used,  and 
as  I  have  just  said,  is  to  be  detected  by  the  specific  gravity. 
Iodine  detects  the  presence  of  starch,  which,  like  gum  and  dex- 
trin, are  added  to  give  thickness.  Annatto  or  turmeric  is  added 
for  the  sake  of  color.  Chalk  is  added  to  give  thickness  and 
color,  and  to  destroy  acidity.  Cream  is  adulterated  with  mag- 
nesia and  arrowroot.  Yolk  of  eggs  is  added  both  to  cream  and 
milk.  When  milk  is  boiled  to  preserve  it,  it  may  take  up  from 
the  vessels  that  are  used,  lead,  copper,  or  zinc. 

When  examined  by  the  microscope,  milk  is  seen  to  consist  of  a 
number  of  round  spherical  bodies  with  dark  margins  floating  in  a 
trans2:)arent  fluid.  When  the  milk  is  fresh  and  healthy,  the  glob- 
ules are  fairly  uniform  in  size,  they  roll  freely  over  each  other, 
and  do  not  collect  together  in  masses.  If  they  do  become  min- 
gled, and  granular  bodies  of  difterent  sizes  are  seen,  whilst  a  few 
globular  bodies  preserve  their  distinct  isolation,  it  cannot  be 
called  good  milk.  Such  a  specimen  of  milk,  known  as  colostrum, 
is  found  in  the  human  female  after  parturition,  and  if  it  does  not 
disappear  on  the  fifth  or  sixth  day,  the  milk  must  be  considered 
unhealthy  and  unfit  for  the  child.     Of  course  we  may  find  in  it, 


MILK    DIET    AND    HYGIENE.  29 

pus,  blood,  epithelium  in  large  amount,  casts  of  lacteal   tubes, 
eeeds,  fungi,  etc. 

The  number  of  the  globules  determines  the  quality  of  the  milk, 
and  thev  are  more  numerous  in  cow's  than  in  human  milk. 

The  analysis  of  chemists  differs  so  widely  that  in  a  work  of  this 
description  it  would  be  beyond  the  mark  to  give  the  results  of  their 
examination.  The  practical  outcome  of  their  investigations  is 
enough  for  our  purpose.  It  is  beyond  dispute  that  cow's  milk  is 
richer  than  human,  and  it  must  therefore  be  diluted  in  order  to 
make  it  resemble  the  latter.  Further,  it  contains  less  sugar,  and 
accordingly  a  small  amount  should  be  added  to  make  up  for  its 
deficient  sweetness. 

When  the  milk  is  acid  it  presents  just  the  same  appearance  as  it 
does  when  treated  with  acetic  acid,  which  causes  the  casein  to 
coao;ulate. 

Seeing  that  the  high  price  of  ordinary  pure  milk  may  in  time 
place  it  beyond  the  reach  of  the  poorer  classes,  it  is  important  to 
inquire  whether  some  of  the  forms  of  "condensed  milk"  lately 
introduced  may  not  be  equally  nutritious,  and  the  milk  be  unaltered 
in  its  qualities,  when  deprived  of  the  water  it  contains.  These 
results  have  been  accomplished  hj  Mr.  Gail  Borden,  of  ISTew  York. 
He  has  invented  a  process  for  converting  milk  into  a  solid,  which 
can  be  kept  pure  for  a  long  period,  and  then  by  the  addition  of 
water  be  brought  back  again  to  its  original  flavor  and  consistency. 
About  three-fourths  of  the  water  are  removed,  so  that  the  milk  is 
in  a  semi-liquid  state,  of  the  consistency  of  honey.  Mr.  Borden 
believes  that  neither  "desiccated,"  powdered,  nor  "solidified" 
milk  can  be  preserved  for  any  length  of  time.  They  require  hot  ■ 
water  to  dissolve  them,  w- hilst  the  condensed  milk  prepared  by 
Mr.  Borden  will  dissolve  at  once  in  cold  water. 

The  condensed  milk  now  known  to  the  public  has  undergone  no 
change  except  the  removal  of  the  water  and  the  addition  of  sugar. 
One  pound  of  the  "  condensed  milk  "  is  equivalent  to  three  or  four 
of  the  crude  milk.  It  is  roughly  estimated  that  about  eight  million 
five  hundred  thousand  pounds  are  manufactured  annually  in  the 
eight  or  ten  factories  in  the  United  States,  or  five  hundred  cases 
of  four  dozen  one-pound  cans  daily. 

The  Anglo-Swiss  Condensed  Milk  Companj^  carried  on  in  the 
commune  of  Cham,  is  conducted  under  the  Borden  process.  It  was 
the  first  to  introduce  condensed  milk  for  family  consumption,  and 


30  DISEASES   OF   CHILDREN. 

it  has  been  followed  by  the  Irisli  Condensed  Milk  Company,  at 
Mallow,  near  Cork,  and  the  English  Condensed  Milk  Company,  at 
Aylesbury.  The  demand  is  already  so  great  that  neither  company 
can  meet  it. 

According  to  Mr.  Willard,  "Dirty  milk,  milk  foul  with  the 
drippings  of  the  stable,  cannot  be  condensed  into  a  clean  flavored 
product."  To  be  so  prepared  it  must  be  uniformly  good.  He  pro- 
ceeds to  make  some  interesting'  observations  on  the  causes  that 
change  milk  into  an  unhealthy  condition,  and  alludes  to  the  well- 
known  researches  of  Hallier  and  Pasteur,  who  consider  that  this 
change  is  brought  about  by  the  presence  of  living  organisms  in  the 
atmosphere  of  germs  from  cesspools  and  putrid  animal  matter,  that 
are  absorbed  by  the  milk,  in  which  they  grow  and  multiply.  He 
alludes  to  the  fungi  theory,  and  quotes  the  words  of  Professor 
Caldwell  on  the  deleterious  eftects  the  microccocus,  the  cryptococ- 
cus,  and  the  penicillium  exert  on  milk,  which  is  peculiarly  suscepti- 
ble to  emanations  from  decomposing  and  putrid  matter.  He  points 
out  that  the  germs  floating  about  in  the  atmosphere,  if  inhaled  by 
the  cows,  will  infect  the  milk  before  it  leaves  the  udder.  He  cites 
the  statement  of  Mr.  Foster,  of  Oneida,  that  cows  inhaling  emana- 
tions from  putrid,  decaying  matter,  yield  milk  unfit  for  making 
cheese.  He  mentions  instances  of  the  milk  being  tainted  from 
cows  passing  through  sloughs  of  decomposing  vegetable  matter. 
Particles  of  dirt  adhering  to  the  udder,  and  finally  falling  into  the 
milk  during  milking,  introduce  germs  which  cause  it  to  decom- 
pose and  putrefy.*  Perhaps  the  most  important  point  is  that  no- 
ticed by  Professor  Low,  of  Cornell  University.  He  observed  in 
the  hot  weather  a  peculiar  ropy  appearance  in  the  cream  which 
had  risen  on  the  milk.  Under  a  powerful  microscope  it  was  found 
to  be  filled  with  living  organisms,  and  he  traced  this  condition  to 
the  cows  having  slaked  their  thirst  from  a  stagnant  pool  for  lack 
of  clear  running  water.  This  water  was  examined  microscopi- 
cally, and  found  to  contain  the  same  class  of  organisms.  The 
blood  of  the  cows  also  yielded  the  same  results.  He  then  obtained 
a  specimen  of  pure  and  good  milk,  and  j)ut  into  it  a  drop  of  water 
from  the  stagnant  pool,  and  in  a  short  time  an  indefinite  number 

*  "  Infusoria  are  sometimes  found  in  milk,  and  fungi  (oidiura  lactis  and  penicillium) 
are  so  almost  invariably  if  the  milk  has  been  kept." — Dr.  Parke's  Practical  Hygiene, 
p.  244,  4th  edition. 

For  some  most  important  observations  on  the  changes  in  sour  milk,  see  Professor 
Lister's  Introductory  Address,  delivered  at  King's  College,  October,  1877. 


MILK   DIET   AND   HYGIENE.  31 

of  these  tiuy  organisms  became  developed  in  the  milk.  The  cows 
were  hot  and  feverish,  as  indicated  by  the  thermometer.  These 
observations  are  highly  interesting  at  the  present  time,  when  poi- 
soned milk  has  recently  introduced  severe  epidemics  of  typhoid. 

The  exact  way  in  which  this  impurity  of  milk  mentioned  by 
Professor  Low  was  brought  about  does  not  materially  affect  the 
question  at  issue.  Whether  it  depends  on  M.  Pasteur's  vital  or 
germ  theory  of  fermentation,  or  on  the  physical  theory  which 
supports  the  view  that  communicable  diseases  are  owing  to  or- 
ganic poisons  neither  independently  reproductive  nor  indestructible, 
is  of  no  moment.  Whether  the  atmosphere  contains  living  germs 
that  induce  putrefaction,  or  particles  of  dead  organic  matter 
which  incite  putrefaction,  does  not  lessen  the  danger  that  milk 
consumers  are  exposed  to.^  Few  questions  can  be  of  more  vital 
importance  to  the  community  at  large,  than  that  which  estab- 
lishes the  fact  of  the  milk  of  the  cows  being  rendered  poisonous 
or  injurious  through  the  water  they  drink,  or  the  food  they  eat. 

Very  little  difference  appears  to  exist  between  the  composition 
of  the  condensed  milk  of  the  English  Company  and  that  of  the 
Anglo-Swiss  Company.  There  is  indeed  a  great  resemblance  be- 
tween them  in  every  respect. 

Constituents  of  Condensed  Milk. 


Water,     .... 
Butter,     .... 
Casein  (including  albumen), 
Sugar  of  milk, 
Cane  sugar, 
Mineral  matter, 


English  Anglo-Swiss 

Company.  Company. 

26.1  to  29.0  25.3  to  27.1 

9.2  to  19.7  9.1  to  10.4 

11.4  to  12.8  10.9  to  13.0 

13.1  to  14.3  14.0  to  14.7 

35.3  to  38.1  361  to  39.0 

2.1  to    2.4  2.0  to    2  4 


Mr.  Bartlett,  in  his  paper  on  "  Condensed  Milk,"t  from  which 
I  have  borrowed  this  analysis,  says  that  all  the  samples  of  con- 
densed milk  are  remarkable  for  their  freshness,  and  that  although 
some  were  open  for  a  fortnight  in  damp  and  warm  weather,  no 
trace  of  milk  fungus  could  be  detected.     The  best  dairy  milk,  ex- 

*  See  the  Journal  of  the  Koyal  Agricultural  Society  of  England,  1872,  vol.  xv,  p.. 
103,  from  which  many  of  the  foregoing  observations  are  gathered.  The  American 
Milk  Condensing  Factories  and  Condensed  Milk  Manufactories,  by  X.  A.  Willard^ 
A.M.,  of  Herkimer,  New  York. 

t  Journal  of  Public  Health,  October  15th,  1873,  p.  187. 


32  DISEASES   OF   CHILDREN. 

posed  for  twelve  or  fifteen  hours,  became  filled  with  myriads  ot 
elongated  bodies  of  fungus  spores,  from  which  the  condensed  milk 
is  preserved,  doubtless  by  the  moderate  but  sufficient  heat  incident 
upon  condensing. 

To  sum  up, — the  chances  of  lactic  acid  fermentation  are  reduced 
in  condensed  milk,  and  this  milk  replaces  human  mother's  milk 
better  than  that  of  the  ordinary  stall-fed  cows  of  large  towns,  which 
is  often,  in  addition  to  its  natural  unfitness  for  infant's  food, 
weakened  by  admixture  with  water,  and  rendered  unwholesome 
by  adulteration.  Several  instances  have  been  brought  under  my 
immediate  observation. 

Some  patients  tell  me  that  their  children  never  throve  until  they 
gave  them  Swiss  milk,  and  the  same  testimony  is  repeatedly  given 
by  hospital  out-patients.  Under  its  use  the  secretions  are  kept 
regular  and  in  good  order ;  the  unhealthy,  slimy,  and  dark  ofi:en- 
sive  motions  of  3'oung  children  are  not  nearly  so  common.  I  can- 
not say  that  there  is  anj^  real  difterence  in  the  nutritive  or  digestive 
properties  of  Aylesbury  over  Swiss  milk,  but  the  latter  is  consid- 
ered by  some  medical  men  to  salt  better  than  the  former,  and  so 
far  as  mj'  observations  go,  Swiss  milk  is  the  most  widel}-  known. 
Swiss  milk  contains  rather  less  casein  and  rather  more  sugar,  which 
may  make  it  more  digestible,  and  likely  to  keep  longer.  The  great 
advantages  of  these  condensed  forms  of  milk  are  that  they  undergo 
few  changes,  and  are  unvarying  in  their  qualities.  They  are  par- 
ticularly adapted,  too,  for  hot  weather,  when  cow's  milk  readily 
undergoes  putrefactive  change,  and  causes  sickness  and  diarrhoea. 
Cases  are  to  be  met  with,  however,  in  which  cow's  milk  suits  best, 
and  after  children  have  passed  the  age  of  three  months  they  do 
not  tbrive  on  the  condensed  forms  of  milk.  This  is  partly  to  be 
explained  on  the  ground  that  wben  cow's  milk  is  employed  we 
dilute  it  with  water,  and  add  sugar  for  the  first  two  or  three 
months,  but  we  gradually  withdraw  the  sugar  and  give  the  milk 
undiluted. 

^lan}^  families  are  in  the  habit  of  receiving  their  milk  in  deep 
jugs  with  narrow  tops,  and  keeping  it  in  small  aud  confined  larders, 
where  it  is  liable  to  be  impregnated  with  the  efiluvia  of  game,  fish, 
etc.  This  odor  has  not  the  same  chance  of  escape  as  when  the 
milk  is  poured  into  shallow,  broad  vessels,  where  it  can  be  kept 
-cooler  with  a  large  evaporating  surface. 

Milk  is  an  organic  fluid  quickly  liable  to  putrefaction  and  fer- 


MILK   DIET   AND   HYGIENE.  33 

mentation,  and  to  become  tainted  and  undergo  change  of  taste  and 
odor  when  left  in  the  vicinity  of  cheese,  tainted  meat,  and  some 
kinds  of  fruit.  Poisons  are  conveyed  through  the  medium  of  the 
atmosphere,  or  through  water,  and  it  is  no  longer  a  disputed  ques- 
tion that  milk  may  also  be  a  disseminator  of  disease.  It  can  ab- 
sorb deleterious  effluvia,  under  the  circumstances  just  alluded  to, 
and  become  unfit  for  human  consumption.  When  we  remember 
how  quickly,  in  hot  weather,  milk  undergoes  putrefaction  and  fer- 
mentation, losing  its  sweetness,  and  becoming  rancid  in  the  course 
of  a  few  hours,  we  have  the  clearest  proof  that  organic  poisons 
may  readily  become  absorbed  by  it  Either  by  air  or  by  water  the 
poison  of  zymotic  diseases  is  conveyed,  and  those  persons  engaged 
in  milking,  who  have  recently  attended  on  the  sick,  may  even 
propagate  the  disease  by  their  hands  or  by  their  clothes. 

Our  experience  of  the  milk  epidemic  of  typhoid  fever,  in  1873, 
opens  our  eyes  still  further  on  another  point.  The  poison  of 
cholera  finding  its  way  into  w^ater,  may  be  spread  through  milk  in 
the  same  manner  as  typhoid  ;  and  the  atmosphere  becoming  con- 
taminated with  the  poison  of  scarlet  fever  and  measles,  may  be 
absorbed  by  the  milk.  In  short,  it  is  not  within  the  scope  of  imagi- 
nation to  realize  the  manner  or  rapidity,  with  which  the  effluvia 
of  contagious  diseases  may  travel,  charging  the  atmosphere  with 
poison,  and  spreading  death  and  desolation  amidst  the  healthiest 
districts. 

The  milk  of  diseased  cows  decomposes  quickly,  and  instead  of  the 
round  oil-globules,  which  are  the  only  constituents  of  healthy  milk, 
colostrum  with  granular  masses,  and  a  large  amount  of  epithelium, 
are  to  be  seen  under  the  microscope.  Casts  of  the  lacteal  tubes 
may  also  be  sometimes  detected.  It  must  appear  self-evident  that 
few  points  can  be  of  greater  practical  importance  than  to  ascertain 
the  chemical  and  microscopical  characters  of  milk  in  all  cases  where 
sick  children  are  living  chiefly  on  it. 

I  now  come  to  consider,  and  that  very  briefly,  what  are  the  dis- 
eases in  which  milk  is  especially  indicated  as  a  medicine.  As  a 
diet  we  recognize  its  value,  and  assign  to  it  the  first  position 
among  all  kinds  of  food.  To  bring  up  children  healthy  and  strong 
milk  in  some  one  of  the  forms  I  have  alluded  to  must  be  provided 
liberally.  Constitutional  weakness  in  children  is  greatly  devel- 
oped by  scanty  and  impure  milk;  hence  we  have  great  mortality 
before  the  age  of  one  year  is  reached.    In  some  of  our  large  manu- 

3 


34  DISEASES   OF   CHTLDREX. 

facturing  towns,  as  Manchester,  Liverpool,  Glasgow,  etc.,  the 
mortality  of  infant  life  is  appalling.  The  Registrar-General's 
return  for  the  year  1871,  shows  that  of  112,535  children  born  within 
the  year,  19,301  died  before  they  reached  the  age  of  one  year. 
Regarding  infant  mortality,  Dr.  Carpenter,  of  Croydon,  says  that 
"  ninety  per  cent,  of  the  children  which  are  put  out  to  drj'^-nurse 
by  wet-nurses,  die  after  a  few  weeks  of  hand-feeding.  This  mor- 
tality is  induced  by  the  administration  of  imjDroper  food.  It  is 
shown  by  the  Registrar-General's  statistics  that  more  than  20,000 
children,  under  one  year  of  age,  die  in  England  every  year  from 
convulsions  ;  that  is,  one  out  of  every  34  dies  within  the  year, 
Tvhilst  in  Scotland  one  only  in  370  dies  from  such  a  cause.  The 
great  difference  between  English  and  Scotch  feeding  among  the 
poor  is  the  cause  of  this  variation ;  the  northern  babies  are  not 
stuffed  with  farinaceous  food  before  they  are  able  to  digest  it ; 
Scotch  mothers  scarcely  ever  feed  their  babies  with  anything  else 
than  that  provided  by  themselves  in  the  first  few  months  of  their 
lives,  and  the  result  is,  that  convulsions  as  a  cause  of  death,  are 
comparatively  rare  in  the  first  year."* 

We  know  that  in  some  children,  and  even  in  adults,  the  diges- 
tive functions  are  so  enfeebled  that  milk  cannot  be  assimilated. 
The  occasional  aversion  to  milk  is  also  well  known,  and  the  dislike 
to  it  cannot  be  overcome.  I  saw  one  child,  six  months  old,  who 
■could  digest  about  half  a  pint  of  milk  daily,  but  if  this  quantity 
was  increased  severe  sickness  followed,  and  the  attempt  to  give 
more  with  lime-Avater  or  plain  water,  or  Dinneford's  solution  of 
magnesia,  was  of  no  avail.  It  w^as  impossible  to  give  it  in  any 
large  quantity,  and  the  diet  was  supplemented  by  veal  broth, 
chicken  broth,  or  weak  beef  tea.  In  some  adults,  severe  discomfort, 
w-eight  and  indigestion,  follow  from  the  continued  employment  of 
milk,  and  it  cannot  be  denied  that  ordinary  cow's  milk  does  tax  or 
interfere  with  the  digestive  power  in  some  cases  if  taken  in  any 
■considerable  quantity  long  together.  It  causes  weight  and  heavi- 
ness and  in  some  cases  constipation,  and  where  this  is  so,  aversion 
or  dislike  is  certain  to  ensue.  Brandy,  soda-water,  lime-water,  dill- 
water,  etc.,  have  been  emplo^^ed  to  overcome  this  objection,  and  in 
a  great  many  instances  the  addition  has  been  successful,  and  the 
coagulation  or  curding  in  the  stomach  has  been  prevented. 

*  Some  of  the  Causes  which  produce  Infant  Mortality  and  Constitutional  Weak- 
ness, by  Alfred  Carpenter,  M.D.,  Public  Health  Journal,  June,  1873. 


MILK    DIET   AND    HYGIENE.  35 

In  all  those  diseases  that  are  of  a  consumptive  or  wasting 
character,  and  where  emaciation  is  going  on,  milk  is  extremely 
valuable,  suitable  to  the  digestive  organs,  containing  all  desirable 
elements  for  the  repair  of  the  body,  and  best  compensating  for  its 
waste. 

In  cases  of  extreme  debility  and  marasmus,  chronic  dyspepsia, 
carcinoma  and  ulceration  of  the  stomach,  gastrodynia,  etc.,  milk  is 
our  sheet  anchor ;  solid  food  cannot  be  tolerated  by  the  digestive 
organs,  and  if  we  had  not  a  remedy  like  milk,  our  patients  would 
literally  die  of  starvation.  I  can  call  to  mind  one  severe  case  of 
gastric  pain  (neuralgia  of  the  stomach)  in  which  milk  was  the 
only  food  taken  for  upwards  of  four  3'ears ;  nothing  but  a  rigid 
adherence  to  this  simple  diet  procured  the  patient  ease,  and  gave 
him  rest  at  night,  instead  of  the  agonizing  suffering  which  he  had 
endured  for  years.  This  patient  had  long  ridiculed  the  idea  of 
living  on  milk ;  indeed,  it  is  only  in  confirmed  states  of  ill  health 
that  patients  can  be  brought  to  understand  that  milk  is  possessed  of 
extremely  nutritive  qualities,  and  is  sufficient  to  maintain  life. 

As  life  advances,  and  more  especially  towards  its  decline,  when 
the  tissues  are  undergoing  degeneration,  and  the  eliminating  func- 
tions are  becoming  impaired  (as  in  structural  degeneration  of  the 
kidney),  milk  may  temporarily  arrest  or  lessen  the  activity  of 
these  changes  and  prolong  existence.  The  skim-milk  treatment 
of  diabetes  is  fresh  in  our  recollection,  and  whatever  doubt  may 
be  thrown  on  its  virtues  as  a  therapeutic  agent,  there  can  be  none 
as  regards  its  nutritive  and  non-irritating  properties. 

In  acute  diseases  of  the  febrile  class,  and  nervous  diseases  gene- 
rally, milk  is  a  powerful  restorative.  In  the  diarrhoea  of  enteric 
fever  and  some  other  profuse  discharges,  heemorrhages  and  loss  of 
blood,  and  great  lactation,  we  have  in  milk  a  valuable  remed}^ 
By  increasing  the  general  nutrition  it  has  the  effect  of  diminish- 
ing the  discharges  from  the  mucous  surfaces. 

Among  children  of  well-to-do  parents,  and  in  the  higher  ranks 
of  life,  I  have  repeatedly  seen  the  advantage  of  giving  them  a 
good  supply  of  milk  morning  and  evening,  before  going  to  bed 
and  on  getting  up.  The  appetite  has  improved,  and  each  meal 
has  been  relished  and  digested  through"  the  milk,  which  has  acted 
like  a  tonic.  These  facts  are,  however,  known  to  all  of  us,  and 
similar  instances  occur  in  our  practice  every  day. 

This  brings  me  to  say  that  milk  is  constantly  underrated  by 


36  DISEASES   OF    CHILDREN. 

parents  and  mothers,  and  credit  is  given  to  certain  patented 
"corn-flours"  to  which  they  are  not  entitled.  We  may  lay  it 
down  as  a  golden  rule  that  unless  food  is  easy  of  digestion  it  fails 
to  be  nutritive.  Many  of  the  forms  of  food  advertised  for  chil- 
dren are  said  to  contain  a  large  percentage  of  earthy  phosphates, 
and  to  be  singularly  rich  in  nitrogenous  or  plastic  materials. 
They  may  be  of  service  where  milk  is  also  freely  supplied,  but 
without  it  they  are  of  questionable  value,  as  they  contain  a 
large  proportion  of  starch,  which  young  infants  are  incapable  of 
digesting.  The  salivarj'-  and  pancreatic  glands  do  not  reach  their 
functional  development  until  the  infant  has  attained  the  age  of 
eight  or  nine  months  ;  and  as  starch  requires  to  be  acted  upon  by 
their  secretions  before  it  becomes  converted  into  a  soluble  sugar, 
it  follows  that  all  farinaceous  foods  are  incapable  of  digestion,  and 
therefore  worse  than  useless  before  that  age  is  reached.  The  true 
function  of  the  saliva  is  to  convert  starch  into  glucose  or  sugar, 
and  unless  it  is  so  acted  on  by  the  salivary  or  pancreatic  secre- 
tions, it  either  passes  through  the  bowels  unchanged  or  undergoes 
lactic  acid  fermentation,  producing  flatulence  and  spasm  by  the 
quantities  of  intestinal  gases  which  are  generated  as  a  consequence.* 
Experiments  have  been  conducted  to  prove  that  the  saliva  of  an 
infant  four  or  five  months  old  has  no  action  on  insufliciently 
cooked  arrowroot,  sago,  tapioca,  and  the  so-termed  "corn-flours," 
but  the  salivary  secretion  of  an  adult  has  considerable  trans- 
forming power.  Still  chemists  are  of  opinion  that  they  are  not 
suitable  for  any  age.f 

In  very  young  children  milk  is  the  only  nourishment  required, 
so  nicely  adjusted  are  its  component  parts,  but  until  we  can  con- 

*  Some  Experiments  on  the  Digestibility  of  Starch  by  Infants,  Journal  of  Public 
Health,  August,  1872,  p.  111. 

t  See  Chap.  XIV,  On  Indigestion. 

It  is  important  to  allude  to  this  fact  of  salivary  secretion  in  infantile  life,  "For  the 
first  few  months  it  appears  that  no  saliva  at  all  is  secreted  ;  and  it  is  true  under  natural 
circumstances,  from  the  character  of  the  food,  and  the  absence  of  masticatory  organs, 
that  it  is  not  required."^Pavy,  On  Food  and  Dietetics,  1875,  p.  527. 

"Tlie  digestion  of  starch  is  accomplished  by  the  saliva  and  pancreatic  juice,  both  of 
which  are  rich  in  diastase.  Diastase  also  exists  abundantly  in  the  liver,  and  in 
smaller  quantities  in  the  intestinal -juice,  in  the  blood,  the  urine,  and  apparently  in  all 
the  intestinal  juices.  Diastase  from  all  these  diverse  sources  appears  to  act  substan- 
tially in  the  same  manner  on  starch,  changing  it  by  a  progressive  hydrolysis  into  sugar 
and  dextrin." — L/iimleian  Lectures  on  the  Digestive  Ferments,  by  W.  Boberts,  M.D., 
F.R.S.,  April,  1880. 


MILK   DIET   AND   HYGIENE.  37 

vince  mothers  and  nurses  that  a  child  can  grow  and  thrive  on  it, 
we  must  expect  the  substitution  or  admixture  of  other  foods. 
Sometimes  we  are  told  the  milk  does  not  agree,  and  on  inquiry 
we  find  that  either  the  nurse  or  the  mother,  if  suckling,  is  out  of 
health,  and  the  milk  as  a  consequence  is  defective  and  ill-suited  to 
nourish  and  sustain  the  child.*  Every  mother  should  know  the 
importance  of  weaning  her  child  at  seven  or  eight  months,  because 
suckling  beyond  this  time  is  likely  to  damage  the  health  of  both. 
If  the  mother  can  nurse  her  child  so  much  the  better.  If  deli- 
cate she  should  not  suckle  during  the  night,  as  it  will  disturb 
her  rest  and  exhaust  her.  When,  however,  the  mother's  milk  is 
scanty,  she  should  not  attempt  to  nourish  the  child  entirely,  but 
give  warm  milk  and  water  out  of  a  bottle.  If  she  cannot  suckle 
it,  it  should  have  equal  parts  of  milk  and  water,  and  it  is  a  good 
plan  to  boil  it  before  putting  it  into  the  bottle.  Let  it  be  sweet- 
ened with  half  a  teaspoonful  of  sugar,  and  see  that  the  tube  and 
bottle  are  well  rinsed  out,  and  kept  perfectly  clean.  It  is  a  bad 
plan  to  overfeed  a  child  at  one  time  ;  the  sixth  part  of  a  pint  of 
milk  is  enough  for  a  meal,  if  the  child  is  under  a  month  old.  If 
the  milk  disagrees,  a  tablespoonful  of  lime-water,  or  sometimes 
the  same  quantity  of  dill-water,  may  be  advantageously  added  to 
each  bottleful.  Regular  feeding  is  of  great  importance  ;  till  the 
child  is  two  months  old,  once  in  two  hours  will  be  often  enough, 
and  afterwards  once  in  three  hours ;  of  course  if  the  child  is  very 
delicate,  it  may  require  to  be  fed  oftener,  but  it  is  an  error  to  put 
it  to  the  breast  every  time  it  cries. 

*  Much  of  the  milk  brought  from  the  country  is  impure.  Many  children  perish 
the  first  year  of  their  existence  from  failure  of  the  digestive  organs  to  support  them, 
and  when  brought  up  by  hand  or  underfed  they  are  prone  to  die  of  bronchitis,  diar- 
rhoea, whooping-cough,  etc.  As  to  farinaceous  diet,  much  may  be  urged  for  and  against 
it;  it  may  cause  cliildren  to  look  plump  and  fat,  but  if  too  long  continued  the  blood 
becomes  thin  and  anajmic,  and  exhaustion,  and  even  fatal  syncope,  are  not  unfrequently 
met  witli  in  these  children. 

At  the  present  day,  however,  farinaceous  foods,  as  corn-flours,  arrowroot,  etc.,  are 
underrated,  if  not  altogether  condemned,  by  many  persons  as  unfit  for  nutrition.  Liebig 
and  some  other  chemists  advocate  this  view,  which  led  to  the  employment  of  too  nitro- 
genous a  diet,  and  so  an  opposite  error  crept  in.  Facts  must  speak  for  themselves,  and 
it  cannot  be  denied  that  we  see  some  yoitng  children  whose  flesh-forming  power  ap- 
pears to  be  due  to  the  nutrition  of  starchy  food.  Abundant  instances  of  the  kind  are 
to  be  met  with  among  the  rural  population  of  England.  It  is  a  point  deserving  con- 
sideration wliether  a  too  exclusively  animal  diet  may  not  sow  the  seeds  in  early  life  of 
a  uric  acid  diathesis,  and  develop  gout  and  Briglit's  disease  with  advancing  years. 


38  DISEASES    OF    CHILDREN. 

In  treating  the  ailments  of  suckling  children,  we  ought  to  ex- 
amine the  milk  of  a  wet-nurse  very  closely,  for  any  error  in  diet 
on  her  part,  or  any  indiscretion  in  drinking,  will  be  certain  to  be 
felt  by  the  child  she  is  bringing  up  ;  mere  emotion,  anger,  or  dis- 
appointment will  influence  the  lacteal  secretion.  Attacks  of 
cramp,  spasm,  flatulence,  emaciation,  and  diarrhoea  in  young  chil- 
dren can  constantly  be  traced  to  dj'spepsia  brought  on  by  the  milk, 
or  the  mental  condition  of  the  nurse,  and  all  the  medicines  we  may 
prescribe  will  prove  but  palliatives  so  long  as  this  state  of  things 
is  suffered  to  go  on.  In  selecting  a  wet-nurse  it  is  very  important 
that  she  should  be  in  good  health  and  spirits,  and  free  from  con- 
stitutional taint.  She  should  be  fully  grown,  and  as  a  rule,  not 
less  than  twenty-two  years  of  age.  Leucorrhoea  is  an  objection, 
and  any  evidences  of  strumous  disease,  as  scars  in  the  neck;  then 
the  most  rigid  inquiry  should  be  instituted  as  to  whether  she  be 
free  even  from  the  suspicion  of  syphilitic  disease.  The  evidence  of 
syphilis  is  somewhat  difficult  to  find  in  the  absence  of  any  active 
manifestations,  but  it  is  always  well  to  search  for  maculfe  and  ul- 
ceration about  the  fauces.  A  few  cases  in  illustration  of  these 
remarks  may  be  here  quoted. 

Case  1. — A  lady  consulted  me  in  February,  1868,  about  her 
infant  which  Avas  five  months  old.  It  was  not  thriving  to  her 
satisfaction,  the  skin  and  muscles  being  lax  and  flabby,  the  bowels 
frequently  relaxed,  and  the  motions  sometimes  consisting  almost 
wholly  of  mucus,  with  an  occasional  streak  of  blood.  There  was 
also  a  good  deal  of  redness  and  excoriation  around  the  anus 
{Intertrigo).  The  nur.-e  who  suckled  the  child  seemed  a  fairly 
healthy  woman,  but  a  microscopic  examination  at  once  showed 
that  the  milk  was  very  deficient  in  the  number  of  oil-globules, 
and  therefore  unfit  for  the  purposes  of  nutrition.  I  recommended 
asses'  milk  to  be  given  alone,  as  digestion  was  weak  and  cows' 
milk  did  not  agree.  The  child  gradually  improved  from  that 
time,  the  bowels  becoming  regular  and  the  motions  healthy.* 

Case  2. — An  infant,  seven  months  old,  was  subject  to  occasional 

*  The  milk  of  the  ass  often  suits  witli  the  delicate  digestion  of  an  adult;  it  is  richer 
in  sugar  and  soluble  salts,  and  contains  less  nitrogenous  matter  and  fat  than  cow's  milk. 
Though  it  is  therefore  adapted  in  particular  cases  to  some  infants  from  the  facility  with 
which  it  is  digested,  its  composition  is  not  rich  enough  for  a  strong  and  thriving  child. 
For  further  information  on  this  point  see  Dr.  Pavy,  On  Food  and  Dietetics,  2d  edition, 
1875,  pp.  185-529. 


MILK   DIET   AND   HYGIENE.  39 

attacks  of  vomiting,  cramp,  and  flatulence.  The  motions  were 
never  two  days  alike,  sometimes  being  hard  and  pebbly  and  light- 
colored,  at  other  times  loose  and  frequent.  The  child  was 
always  uneasy  after  food,  unless  an  attack  of  diarrhoea  or  vomit- 
ing came  on,  when  it  usually  became  quiet  or  fell  asleep.  The 
child  was  fed  on  cow's  milk,  sweetened  and  diluted  with  water, 
and  biscuits  were  generally  added.  It  is  quite  clear  that  this 
method  of  feeding  did  not  agree  with  it,  indigestion  being  a 
marked  feature  of  the  child's  sufferings.  It  was  found  that  the 
milk  was  not  good,  and  in  addition  to  the  biscuits  which  disa- 
greed, and  increased  the  amount  of  flatulence,  the  child  was  fed 
at  irregular  hours,  and  the  stomach  loaded.  New  and  good  milk 
was  now  procured,  and  a  small  quantity  of  dill-water  was  added, 
all  biscuit  food  and  farinaceous  articles  being  solemnly  forbidden. 
The  child  almost  immediately  began  to  improve,  and  at  the  end 
of  two  months  had  grown  plump  and  strong  without  a  sign  of 
discomfort. 

Case  3. — A  lady  requested  me,  in  April,  1868,  to  visit  her  child, 
who  was  then  six  months  old.  The  child  was  fat  and  plump,  and 
always  inclined  for  food,  which  he  took  greedily.  When  he  was 
not  eating  he  fell  asleep.  The  only  complaint  made  was  that  the 
bowels  were  habitually  confined,  and  that  in  consequence,  aperient 
medicines  had  to  be  constantly  resorted  to.  The  motions  were 
very  hard  and  pale,  the  child  often  crying  when  straining  to  empty 
his  bowels.  It  was  evident  to  me  that  the  child  was  overfed,  and 
I  persuaded  with  some  difliculty  that  he  should  be  restricted  to 
milk-and-water.  In  the  shape  of  medicine  nothing  was  ordered 
except  a  two-ounce  enema  of  soap  and  water  to  be  thrown  into 
the  bowel  early  every  morning,  and  pressure  to  be  applied  at  the 
anal  aperture,  that  it  might  be  retained  a  little  time. '  This  was 
enough  to  act  as  a  gentle  stimulus  to  the  liver,  and  to  regulate 
the  bowels,  without  any  other  mode  of  treatment.  Here  was  a 
child  of  sound  and  vigorous  constitution,  that  would  have  thriven. 
on  that  upon  which  another  child  would  have  starved,  and  when 
this  simple  regulation  of  diet  was  enforced,  no  further  remedies 
were  required. 

Instances  of  this  kind  are  repeatedly  met  with  where  constipa- 
tion is  the  chief  symptom.  The  child's  bowels  act  once  in  two  or 
three  days,  whilst  the  appetite  is  good,  and  the  condition  is  in 
every  other  respect  healthy.     The  motions  are  deficient  in  moist-- 


40  DISEASES   OF    CHILDREN. 

lire,  and  painful  to  pass  tbroiigli  the  anus,  which  becomes  red  and 
tender.  The  little  suflf'erer  screams  in  its  straining  efforts  to  evac- 
uate the  impacted  mass.  This  nursery  trouble  may  set  in  soon 
after  birth,  and  add  to  the  risk  of  teething.  The  liver  in  these 
cases  does  not  act  well,  and  the  small  intestines  fail  to  furnish 
their  due  amount  of  secretion,  and  the  rest  of  the  intestinal  tube 
becomes  sluggishlj-  passive  in  propelling  its  contents.  Overfeed- 
ing causes  this  troublesome  constipation  as  often  as  underfeeding 
induces  diarrhoea  and  exhaustion.  But  the  cause  is  not  always 
ascertainable.  In  some  cases  I  have  been  inclined  to  regard  it  as 
constitutional.  It  occurs  occasionally  where  the  mother's  milk  is 
healthy,  and  microscopically  faultless. 

The  mother  may  be  weak  and  languid,  notwithstanding  the 
good  character  of  her  milk,  and  if  her  health  is  not  attended  to 
the  milk  will  become  impoverished,  and  the  child  suffer  in  other 
ways.  -Mere  constipation  in  the  child  is  no  evidence  that  the  milk 
is  at  fault,  but  when  given  too  frequently  and  abundantly  it  de- 
ranges the  hepatic  functions.  In  these  cases  of  otherwise  healthy 
children  a  saline  aperient  given  at  bedtime,  and  repeated  early  in 
the  morning  is  a  good  remedy.*  After  a  few  doses  the  bowels 
begin  to  act  more  regularly,  and  the  motions  become  soft.  In 
alternation  with  the  mixture  the  soap  enema  is  an  excellent  rem- 
edy. As  the  nurse  sits  with  the  child  in  her  lap  before  a  fire, 
friction  with  the  hand  for  a  short  time,  morning  and  evening,  over 
the  abdomen  acts  as  a  capital  stimulant  to  sluggish  bowels.  We 
now  and  then  meet  with  another  class  of  cases  in  which  the  mo- 
tions are  moist  and  of  proper  color,  but  considerably  larger  and 
firmer  in  consistence  than  we  expect  to  find  in  infants  of  five  or 
six  months  old.  The  bowels  will  not  act  without  an  enema  or  an 
aperient  of  some  kind,  and  parents  become  alarmed  if  this  goes 
on,  as  it  often  will  in  spite  of  any  treatment,  till  dentition  sets  in. 
When  there  is  no  mechanical  obstacle,  as  hernia,  imperforate  rec- 

*  Formula  1 : 

R.  Magnes.  sulph., .^j 

Tinct.  rliei, 5s-<. 

Vel  syr.  rliei,    .         .         .         .         .         .         .         .         .  ,^ss. 

Vel  syr.  zingib., Si.j 

Tinct.  cinnam.  comp., .o.j 

Aquam  anethi  ad, Si.j. — M. 

One  to  two  teaspoonfuls  to  be  taken  at  bedtime  and  in  the  early  morning,     I'or  a 
child  five  or  six  months  old. 


MILK    DIET   AND   HYGIEXE.  41 

turn,  or  invagination,  the  fault  may  in  most  instances  be  attributed 
to  the  food.  If  the  general  health  of  the  child  should  keep  good, 
no  harm  will  follow  from  this  form  of  constipation.  The  aperient 
must  be  varied  from  time  to  time,  and  the  enema  used  in  change 
Avith  it.  When  simple  remedies  fail,  a  teaspoonful  of  the  decbct. 
aloes  comp.,  or  a  grain  or  two  of  scammony  or  jalap,  or  even  an 
occasional  mercurial  will  rouse  the  torpid  liver  and  inactive  vis- 
cera, and  promote  the  passage  of  bile  and  mucus.  It  sometimes 
happens  that  immediately  a  tooth  penetrates  the  gum  the  symp- 
toms improve  and  the  constipation  departs.  In  other  cases  the 
constipation  is  troublesome,  and  an  enema  has  to  be  given  every 
third  or  fourth  day  till  the  child  can  run  about  and  take  exercise. 

Milk  mixed  with  bread,  as  children  grow  older,  is  very  excel- 
lent. For  my  own  part,  I  have  much  faith  in  the  familiar  expres- 
sion, "Bread  is  the  statf  of  life;"  and  if  we  want  to  know  its 
nourishing  properties  we  have  only  to  look  at  our  village  popula- 
tion. Many  healthy  chiklreu  from  the  age  of  three  months  thrive 
on  this  diet,  and  grow  up  strong  and  healthy.  Scotch  oatmeal  is 
another  valuable  article  of  diet ;  it  is  very  nutritious,  and  regu- 
lates the  action  of  the  bowels  better  than  an3'thing  else  with  which 
I  am  acquainted.  It  should  be  mixed  with  milk,  and  may  be 
given  to  children  from  the  age  of  one  year. 

Of  course,  differences  of  situation  necessitate  differences  of  treat- 
ment, and  children  of  delicate  parents,  living  in  a  vitiated  atmos- 
phere require  a  special  diet.  At  seven  months  old  the  child  may 
have  milk,  to  which  Eobb's  biscuits  or  Liebig's  food  may  be  added, 
or  well-baked  bread.  The  child  should  have  plenty  of  warm  milk 
in  addition.  At  ten  months  old  it  should  have  weak  broth  or 
beef  tea.  When  a  year  and  a  half  old  it  may  have  pounded  meat, 
with  a  little  gravy,  or  meat  cut  up  very  line.  Much  will  depend 
upon  the  natural  strength  and  constitution  of  the  child ;  but  solid 
animal  food  should  not  be  given  till  it  is  two  years  old.  Hospital 
patients  have  repeatedly  told  me  that  milk  alone  would  not  satisfy 
the  hunger  of  their  children,  and  before  bottles  came  into  fashion 
I  have  often  seen  strong  and  health}'  children,  at  four  or  live  months 
old,  being  fed  with  milk  thickened  with  bread;  whereas,  among 
the  verj^  poor  in  rural  districts,  gruel  has  in  many  instances  been 
the  only  article  of  diet.  A  delicate  child  would  break  down 
under  this  system  of  feeding,  but  in  those  who  are  thriving  and 
breathing  pure  air  it  has  no  prejudicial   effects.     Whether  the 


42  DISEASES    OF    CHILDREN. 

child  be  strong  or  delicate,  milk  should  be  the  chief  article  of  diet 
till  the  age  of  two  years;  and  the  continuance  of  debility  should 
be  an  indication  to  persevere  with  the  milk  pure  and  alone.  It  is 
a  popular  error  among  mothers  that  milk  must  soon  give  place  to 
solid  food,  and  yet  those  whose  practice  lies  among  children  wnll 
often  observe  a  child  at  eight  or  nine  years  of  age,  with  a  good 
appetite,  eating  meat  three  times  a  day,  grow  thin,  pallid,  and 
languid.  These  children  have  delicate  digestions,  the  tongue  is 
indented  at  the  sides,  the  back  coated  with  a  whitish  fur,  and 
there  are  superficial  abrasions  of  the  mucous  membrane,  all  indi- 
cating extreme  feebleness  of  digestive  power,  amounting  to  slow 
starvation.*  Place  such  a  child  on  a  diet  of  milk  and  he  begins 
to  thrive  at  once;  his  tongue  gradually  improves,  his  bowels  are 
regular,  and  he  gains  flesh  and  strength  with  surprising  rapidity. 
If  you  can  induce  the  parents  of  such  a  child  to  give  him  a  basin- 
ful of  milk-and-bread  for  breakfast  instead  of  tea,  and  let  him 
have  well-minced  mutton  or  chicken  once  a  day,  and  cod-liver  oil, 
he  will  throw  ofi'  his  delicacy,  and  the  rest  will  have  enabled  his 
digestive  organs  to  gain  strength. 

When  children  have  cut  their  incisor  teeth  they  are  liable  to 
feverish  discomfort  and  restlessness;  they  alarm  the  nurse  and  the 
mother  by  starting  in  sleep  and  exhibiting  a  spasmodic  movement 
of  the  lips  and  eyelids.  If  we  examine  the  mouth  in  such  cases 
we  shall  generally  observe  that  the  gums  are  red  and  tender,  and 
although  other  teeth  are  not  appearing  nor  distending  the  gum, 
they  are  probably  at  no  great  distance.  It  is  always  well  to  punc- 
ture this  inflamed  gum  with  a  lancet,  and  to  give  a  freely  acting 
purge.  If  the  child  is  strong  enough,  let  it  contain  a  grain  of 
calomel,  for,  much  abused  as  this  drug  is,  and  told  as  we  are  on 
evidence  that  seems  conclusive,  that  it  does  not  increase  the  secre- 
tion of  bile,  I  know  not  where  to  find  any  purgative  or  alterative 
medicine  that  acts  so  efliciently  in  many  of  the  diseases  of  early 
life.  Let  it  be  given  on  an  empty  stomach,  and  do  not  deny  the 
child  if  old  enough,  a  drink  of  cold  water,  or  of  toast-and-water. 
This  is,  however,  at  best  a  critical  period  with  children,  requiring 
much  care  and  watchfulness  on  onr  part.  The  nervous  system  is 
easily  affected,  and  the  digestive  functions  are  readily  upset,  which 
would  be  less  likely  later  on.     The  extreme  frequency  of  convul- 

*  See  Cliap.  XVI,  On  Indigestion. 


MILK    DIET    AND    HYGIENE.  43 

sions  in  early  life  should  always  be  borne  in  mind  whenever  the 
system  is  out  of  order,  and  the  medical  attendant  should  never 
lose  sight  of  the  liability  to  them  in  young  children,  however  well 
a  case  of  illness  maj^  be  progressing. 

The  balance  between  health  and  disease  is  so  delicately  adjusted 
in  early  life,  that  a  very  slight  disturbing  cause  will  incline  it  to 
one  side  or  the  other.  Health  and  disease  hold  close  relationship, 
and  we  are  often  perplexed  to  know  where  one  ends  and  the  other 
begins.  Where  medicines  are  necessary,  it  is  very  important  that 
they  should  be  prescribed  in  as  agreeable  a  form  as  possible,  A 
medical  man  will  often  get  much  credit  by  ordering  his  medicines 
pleasant  to  the  taste;  and  there  are  very  few  drugs  really  neces- 
sary for  children  which  cannot  be  given  in  a  pleasant  form.  Some 
practitioners  there  are,  however,  who  seem  never  to  have  con- 
sidered this  matter,  and  as  a  consequence,  many  of  their  medi- 
cines are  thrown  aside  by  the  mother  or  the  nurse,  who,  ralher 
than  hear  the  shrieks  of  the  child,  gives  up  the  effort  to  adminis- 
ter them.  I  think  a  certain  degree  of  tact  and  judgment  is 
required  in  prescribing  for  young  children. 

The  habit  of  giving  j'oung  children  wine  and  beer  is  a  verj''  bad 
one;  their  digestive  organs  require  no  stimulants  to  aid  the  pro- 
cess of  digestion,  as  is  the  case  in  after-life,  when  the  stomach 
loses  its  tone  and  becomes  enfeebled,  and  where  a  glass  of  wine  is 
necessary  before  the  patient  can  either  fanc}^  or  digest  his  food. 
Some  of  the  strongest  and  healthiest  children  I  have  ever  seen  have 
been  those  whose  diet  has  been  the  plainest,  and  where  stimulants, 
cheese,  and  pastry  have  been  ranked  with  objectionable  nursery 
drugs,  as  gray  powder,  cordial  mixtures,  and  teething  powders. 
In  illness,  and  especially  in  acute  disease,  where  time  is  valuable, 
stimulants  may  be  demanded ;  and  in  my  own  experience,  I  have 
several  times  known  young  children  recover  from  acute  diseases 
in  consequence  of  their  administration.  The  following  is  a  typi- 
cal case: 

Case  4. — A  healthy  child,  ten  weeks  old,  was  sutiering  from 
troublesome  catarrh,  in  February,  1870.  Tbe  child  was  restless 
and  could  not  suck  comfortably,  owing  to  the  obstructed  state  of 
the  nostrils.  Bronchitis,  confined  to  the  upper  tubes,  ensued,  and 
alarming  prostration  set  in.  The  cough  was  very  harassing  from 
the  accumulation  of  phlegm,  and  there  was  great  flatulence  and 
irregularity  of  the  bowels.     The  mother,  at  my  request,  reluctantly 


44  DISEASES   OF   CHILDREN. 

consented  to  give  up  suckling.  The  child  was  fed  on  ass's  milk,  of 
which  he  took  two  pints  in  the  twenty-four  hours,  mixed  with 
four  small  teaspoonfuls  of  brandy.  He  was  also  fed  with  a  little 
beef  tea  three  or  four  times  a  day,  with  a  few  drops  of  brandy. 
This  last  soon  appeared  to  irritate  the  bowels,  and  was,  therefore, 
discontinued.  In  the  shape  of  medicine,  he  took  half  a  grain  of 
carbonate  of  ammonia  in  s^-rup  of  tolu  and  water  every  four  hours. 
The  temperature  of  the  room  was  kept  at  70°,  and,  what  I  have 
found  of  great  value  in  the  pulmonary  affections  of  young  children, 
the  chest  was  covered,  back  and  front,  with  cotton-wool ;  and  this 
was  allowed  to  remain  on  during  the  critical  state  of  the  child's 
illness.  Bej'ond  attention  to  cleanliness,  the  child's  clothes  were 
not  removed  during  the  illness.  This  is  a  great  point  to  look  to 
in  dangerous  disease.  The  fatigue  and  exhaustion  that  result 
from  frequently  dressing  and  undressing  a  young  child  are  not 
considered,  and  the  repose  and  rest,  which  are  valuable  aids  to 
treatment,  are  altogether  overlooked.  The  temperature  ran  as 
high  as  in  genuine  fever,  but  on  administering  suitable  food  and 
medicine  it  fell,  and  the  child  rapidly  improved.  I  have  known 
this  high  temperature  cause  much  alarm  among  medical  men  ;  but 
it  must  not  deceive  us,  especialh"  with  children,  who,  from  mere 
gastric  disturbance,  will,  in  the  course  of  a  few  hours,  become 
burning  hot. 

There  is  nothing  more  important  than  air  and  exercise  for  chil- 
dren *  When  shut  up  in  the  house  they  become  fractious  and 
irritable,  losing  their  color  and  appetite,  and  becoming  very  way- 
ward and  difficult  to  manage.  The  natural  disposition  of  a  child 
maj^  be  greatl}^  determined  by  being  habitually  shut  up  in  a  room, 
and  deprived  of  proper  air  and  exercise.  In  the  house  it  soon  tires 
of  its  amusements,  but  when  carried  in  the  open  air  fresh  objects 
continually  meet  its  eye  and  engage  its  attention  ;  digestion  is  im- 
proved and  healthy  sleep  promoted.  Children  who  live  in  London 
and  other  large  cities  exhibit  in  a  most  remarkable  degree  the 
salutary  effects  of  country  air,  and,  when  they  have  been  kept  from 


*  "Life  and  health  walk  hand  in  hand.  Health  is  nothing  but  integrity  of  life; 
disejise  is  nothing  but  an  offence  and  abbreviation  of  it.  Gymnastic  exercises  will  not 
under  all  circumstances  be  successful,  but,  eceteris  paribus,  it  will  be  in  creating  fine 

men Exercise,  whether  pleasing  or  not  pleasing,  is  equally  advantageous.     The 

same  degree  of  perspiration,  the  same  muscular  action,  is  produced;  the  same  results 
of  sound  repose,  strength,  and  health  necessarily  follow." — Physical  Education,  Mac- 
niillan,  pp.  3-17  and  303,  Se])teraber,  1873,  No.  165, 


MILK    DIET   AND    HYGIENE.  45 

falling  into  ill  health  b}^  the  tenderest  and  most  judicious  care, 
they  revive  under  the  influence  of  change  with  a  rapidity  that  is 
trul}^  astonishing.  In  densely  populated  places  foul  and  impure 
gases  are  breathed  into  the  system,  and  carried  into  the  blood, 
which  only  the  pure  oxj'gen  of  the  country  can  remove. 

If  eating  a  heavy  meal  on  going  to  bed,  or  indulging  in  tea  and 
coffee  after  a  good  dinner,  tend  in  some  adults  to  cause  sleepless- 
ness, melancholy  dreams,  throbbing  headache,  and  cardiac  pulsa- 
tion, sending  children  to  bed  exhausted  and  with  empty  stomachs 
will  also  equally  cause  discomfort.  Such  children  dream,  and  are 
restless  in  their  uneasy  sleep  ;  they  toss  the  clothes  off,  and  are 
peevish  and  tired  when  they  are  roused  to  dress  and  get  up  in  the 
morning.  If  jaded  by  long  walks  and  the  strain  of  school,  inter- 
rupted digestion  is  indicated  by  fatigue,  and  they  are  sent  to  bed 
too  exhausted  to  obtain  refreshing  sleep.  Children  should  have  a 
light  meal  half  an  hour  before  retiring  to  bed  ;  a  sandwich  or  a 
slice  of  bread  and  butter  will  in  most  cases  suffice  to  satisfy  the 
craving  stomach  and  allay  the  fainting  empty  feel.  If  food,  how- 
ever nutritious,  is  given  them  at  this  time,  when  they  are  too  ex- 
hausted, and  the  nervous  force  which  should  have  been  reserved 
for  the  stomach  has  been  expended  in  active  locomotion,  we  only 
aggravate  the  evil.  The  feeble  stomach  as  much  resents  the  pres- 
ence of  food  as  the  weak  eye  resents  the  light.  Let  us  bear  in 
mind  that  a  child  requires  more  sleep  than  a  grown-up  person, 
because  tissue  change  is  much  more  energetic,  and  the  organs  de- 
mand more  rest  for  their  repair  and  growth.  The  digestive  system, 
too,  requires  the  frequent  administration  of  suitable  food,  that  the 
absorbent  process,  with  its  varied  chemical  changes,  may  be  actively 
carried  on. 

Cold-bathing  is  another  aid  to  health,  and  the  sooner  this  is  be- 
gun the  better.  It  is  the  foundation  of  much  subsequent  good 
health.  With  a  good  circulation  there  is  nothing  more  calculated 
to  keep  the  skin  in  a  healthy  state ;  for  on  it  depends  to  a  very 
great  extent  the  regularity  of  every  function  in  the  child.  When 
early  practiced,  children  will  grow  up  to  revel  in  the  luxury  of 
cold  water,  coming  out  of  it  with  a  skin  at  first  mottled  like  the 
slate-gray  lines  that  permeate  hard  soap ;  and  subsequently  under 
friction,  gradually  becoming  red,  as  the  blood  passes  more  quickly 
through  the  capillaries.  The  tonicity  of  these  vessels  is  increased, 
and  that  relaxation  and  debility  which  render  them  helpless  to 


46  DISEASES   OF   CHILDEEX. 

contract  on  exposure,  is  in  a  great  measure  guarded  against. 
AVhen  the  latter  condition  exists,  children  are  very  liable  to  cold 
and  affections  of  the  respiratory  organs.  A  cool,  elastic,  and  firm 
skin  is  an  indication  of  health,  and  often  by  it  alone  the  medical 
attendant  is  able  to  decide  on  the  state  of  his  little  patient. 

Daily  intercourse  with  disease  can  alone  teach  us  bow  to  pre- 
scribe. Aperient  medicines  should  be  delayed  as  long  as  possible, 
but  if  they  must  be  resorted  to  they  should  be  of  the  simplest 
kind  ;  and  whenever  I  can,  I  always  endeavor  to  avoid  bulky  pow- 
ders. Frequently  they  are  not  properly  mixed,  and  as  often  they 
are  not  swallowed,  and  so  we  are  disappointed  in  our  cases.  The 
aromatic  syrup  of  senna  is  not  difficult  to  administer,  and  the 
syrup  of  rhubarb  is  enough  to  move  the  bowels  of  young  chil- 
dren, regularly  and  efficiently,  if  continued  a  little  time,  and  there 
be  no  necessity  for  promptitude  in  our  measures. 

Honey  or  treacle  spread  on  bread  is  a  favorite  laxative  with 
some  persons.  The  syrup  of  roses  maj^  be  given  with  an  equal 
quantity  of  castor  oil,  and  there  are  few  children  who  will  not 
take  it.  Infants  of  a  few  weeks  or  months  old  will  suck  readily 
a  teaspoonful  of  a  mixture  made  with  castor  oil,  white  sugar,  and 
carbonate  of  magnesia,  with  two  minims  of  oil  of  dill  to  the  ounce 
(Form.  23).  It  is  a  good  combination  where  there  is  costiveness 
and  painful  flatulence.  Diuneford's  solution  of  magnesia  is  a  safe 
and  useful  antacid  and  aperient  for  young  children,  dispelling  flat- 
ulence, and  gently  stimulating  the  peristaltic  action  of  the  bowels. 
An  equal  quantity  of  syrup  of  rhubarb  may  sometimes  be  advan- 
tageouslj^  combined  with  it.  In  feverish  states,  with  constipation, 
young  children  will  take  a  mixture  containing  a  grain  or  two  of 
nitrate  of  potash  with  a  few  grains  of  sulphate  of  magnesia,  when 
s-weetened  (Form.  8).  In  hot  and  excited  states  of  the  system  we 
may  order  with  most  excellent  eflect,  a  purgative  and  alterative 
lozenge  composed  of  one  grain  of  calomel  and  two  grains  each  of 
scammony  and  jalap.  It  is  well  to  order  it  to  be  given  the  last 
thing  at  night,  as  it  then  empties  the  bowels  fully  and  eflect ually 
early  in  the  morning.  It  causes  copious  and  full  evacuations, 
freely  unloading  the  liver  and  small  intestines ;  and  in  cases  of 
feverish  excitement,  it  has  acted  in  my  hands  like  a  charm* 

How  frequently  do  we  see  the  ill  eflects  of  aperient  medicines, 

*  See  Chap.  XVII,  On  Constipation,  where  this  Bubject  is  more  fully  considered. 


MILK    DIET   AND    HYGIENE.  47 

adopted  and  had  recourse  to  on  any  accession  of  real  or  fancied 
ailment.  If  the  medicine  employed  is  simply  of  a  laxative  char- 
acter, and  the  child  is  in  even  tolerably  fair  health,  the  mere  evac- 
uation of  the  intestinal  contents  can  do  no  harm,  and  the  child  is 
none  the  worse  if  not  the  better  for  the  experiment.  But  many 
are  not  satisfied  with  this  mild  class  of  remedies,  and  thej^  select 
some  cathartic  purge  which  throws  the  intestines  into  violent  com- 
motion, unduly  stimulating  and  exciting  the  mucous  follicles,  and 
irritating  the  whole  intestinal  tube.  The  stomach,  liver,  and  pan- 
creas, are  disturbed  in  their  quiet  functions,  and  the  furred  tongue 
is  a  sign  of  weakness  and  temporarily  deranged  stomach,  from  the 
unnecessary  employment  of  medicine.  Such  medicines  are  enough 
to  enfeeble  and  suspend  digestive  power,  and  to  create  as  much 
disturbance  as  a  mass  of  indigestible  matter  in  its  passage  from 
the  stomach  through  the  bowels. 

Children  are  often  brought  to  us,  looking  pale  and  languid,  with 
a  dark  areola  under  the  eyes  and  a  furred  tongue.  We  ascertain, 
perhaps,  that  the  trustworthy  nurse  considers  them  bilious,  and 
gives  them  gray  powder  once  or  twice  a  week.  They  have  very 
little  appetite;  the  bowels  do  not  act  for  want  of  power  ;*'they 
complain  of  being  tired  and  are  glad  to  go  to  bed.  These  are  the 
cases  which  run  into  ansemia ;  enlarged  glands  spring  up  about 
the  neck,  and  if  there  happen  to  be  a  strumous  taint,  we  get  ab- 
dominal or  pulmonary  disease.  The  syrup  of  the  hypophosphite 
of  iron,  with  or  without  quinine,  is  very  valuable,  and  Parrish's 
chemical  food  (Syr.  Ferri  Phosph.  co.)  will  efiect,  in  such  cases  of 
pure  debility,  a  marked  improvement  in  the  health  and  appear- 
ance of  children.  The  syrup  of  the  iodide  of  iron,  in  cases  of 
anaemia  with  a  disposition  to  swollen  cervical  glands,  is  a  well- 
known  but  overrated  remedy.  I  am  very  doubtful  if  it  possesses 
any  real  value.  We  may  employ  it  in  many  cases  of  chronic  cough 
and  debility,  with  or  without  a  few  drops  of  ipecacuanha  wine; 
where  we  have  any  reason  to  suspect  a  tubercular  origin  we  may 
give  it  very  early.  The  Vinum  Ferri  is  a  slightly  astringent  prep- 
aration. We  may  sometimes  prescribe  with  good  effect  a  steel 
powder,  consisting  of  one  grain  of  sulphate  of  iron  and  three  grains 
of  sugar.  Children  take  it  with  a  relish,  either  in  water,  sherry, 
or  ginger  wine.  It  is  a  cheap  tonic,  and  is  very  available  for  hos- 
pital patients.  A  most  excellent  preparation  is  reduced  iron  (Fer- 
rum  Redactum) ;  it  is  a  valuable  remedy  in  ansemia,  chorea,  and 


48  DISEASES   OF   CHILDREN. 

general  debility.  A  grain  or  two  may  be  given  on  bread-and-but- 
ter twice  or  three  times  a  day.  It  has  the  advantage  of  being 
tasteless,  and  a  very  small  dose  is  required.  Then  there  is  the 
iron  lozenge  (Troch.  Ferri  lledacti),  which  no  child  will  refuse  to 
take.  Each  lozenge  contains  one  grain  of  reduced  iron,  mixed 
with  relined  sugar  and  gum  acacia ;  one  may  be  taken  after  each 
meal. 

It  is  not  advisable,  as  a  rule,  to  prescribe  for  children  prepa- 
rations of  iron  with  quinine,  as  the  bitter  being  objected  to, 
the  medicine  runs  the  risk  of  not  being  regularly  administered. 
Iron,  too,  is  much  more  valuable  as  a  tonic  than  quinine;  it  is  less 
stimulating,  is  a  good  blood  restorer,  and  strengthens  and  invigo- 
rates the  nervous  and  circulating  systems,  on  which  the  regular  per- 
formance of  all  the  bodily  functions  depends.  These  forms  of  iron 
regulate  the  bowels  by  the  gentle  stimulus  they  impart  to  the 
muscular  fibre  of  the  intestines,  and  the  alteration  they  effect  in 
the  constituents  of  the  blood.  Dissatisfaction  is  sometimes  felt  at 
the  apparent  inertness  of  these  agents,  but  this  often  arises  from 
their  being  discontinued  too  soon,  or  not  given  regularly.  We 
labor  under  great  disadvantage  in  all  chronic  forms  of  illness,  as 
the  necessity  to  give  medicines  according  to  the  rules  laid  down  by 
the  medical  attendant  does  not  seem  of  sufiicient  importance,  and 
where  cases  are  tedious  and  protracted,  friends  and  nurses  are  apt 
to  grow  negligent  and  indifferent.  In  acute  forms  of  disease 
they  are  more  regularly  given,  and  hence  they  often  obtain  a  credit 
which  is  not  their  due. 

Antimony  is  a  medicine  seldom  required  in  the  ailments  of  young 
children.  It  is  so  depressing  that  unless  the  disease  is  urgent,  as 
in  croup,  and  a  few  other  diseases,  we  may  dispense  with  it  and 
choose  ipecacuanha,  which  is  not  so  lowering,  frequently  as  effective, 
and  much  more  manageable. 

Emetics  are  often  required  for  infants  and  young  children,  who 
vomit  readily,  the  act  being  accomplished  without  the  straining 
and  distress  which  are  experienced  in  adults,  because  the  stomach 
is  not  so  conical  in  form  as  in  later  life,  but  is  more  elongated,  and 
resembles  rather  a  dilatation  of  the  intestines.  Emetics  should  be 
withheld  from  children  with  head  aftections;  in  peritonitis  or  acute 
abdominal  diseases,  or  where  tliere  is  great  debility ;  but  in  the 
early  stage  of  many  disorders,  as  in  croup,  they  promote  the  free 
action  of  the  skin,  and  at  a  later  stage  favor  the  expulsion  of  false 


MILK    DIET    AXD    HYGIENE.  49 

membrane  from  the  trachea.  In  whooping-cough,  pneumonia, 
bronchitis,  and  the  early  stages  of  the  exanthemata,  emetics  are  of 
great  utility  in  reducing  the  force  and  fulness  of  the  pulse,  in 
lowering  the  tension  of  the  vascular  system,  and  in  promoting 
secretion.  The  thick  and  tenacious  secretion  which  clings  to  the 
glottis  in  whooping-cough  becomes  thinner  and  more  easily 
detached  by  their  action,  w^hilst  the  hypergemia  of  the  bronchial 
mucous  membrane  is  lessened.  Emetics  are  serviceable  during  the 
invasion  of  acute  tonsillitis;  in  some  forms  of  acute  indigestion  and 
dyspepsia  they  are  also  useful  by  exciting  the  liver  to  freer  action, 
and  removing  morbid  secretions  from  the  stomach.  An  emetic 
repeated  twice  or  three  times  a  day,  followed  by  a  little  warm  water 
to  insure  its  complete  effect,  is  preferable  to  one  large  dose. 

Sedatives  are  remedies  not  to  be  recklessly  employed  in  the  dis- 
eases of  young  children.  The  sooner  ignorant  minds  are  made 
aware  of  the  dangers  they  incur  in  giving  these  medicines  without 
medical  advice,  the  more  chance  is  there  of  rearing  strong  and 
healthy  children.  The  influence  of  the  profession  should  be 
brought  to  bear  upon  the  indiscriminate  sale  of  soothing  or  teeth- 
ing powders,  and  the  public  should  be  cautioned  against  them. 
Under  the  prevalent  and  frequently  erroneous  notion  that  children 
are  suffering  from  their  teeth,  a  poor  woman,  to  keep  her  child 
quiet,  or  to  get  a  night's  rest  herself,  gives  it  a  teething  powder  to 
send  it  to  sleep.*  Where  there  is  great  excitement  of  the  nervous 
and  vascular  systems  sedatives  are  sometimes  employed  with  great 
advantage,  llyoscyamus,  hydrocyanic  acid,  and  the  compound 
tincture  of  camphor  are  so  important  to  us  that  we  should  Hud  it 
difficult  to  get  on  without  them.     Tincture  of  opium,  however, 

*  "In  November,  1874,  four  children  died  at  Komford  after  taking  'teething 
powders,'  and  death  was  preceded  in  all  of  them  by  stu]ior,  drowsiness,  and  insensi- 
bility. These  dangerous  symptoms  set  in  soon  after  the  powders  were  given,  and  were 
clearly  due  to  an  overdose  of  opium.  Dover's  powder  appears  to  have  been  the  form 
in  which  opium  was  administered." — British  Medical  Journal,  Nov.  14th,  1874,  p.  622. 

"In  1846  I  also  was  distressed  to  find  the  use  of  opiates  among  children  very  preva- 
lent in  manufacturing  districts.  In  this  case  the  motive  was  not  criminal,  for  the 
practice  had  arisen  in  ignorance  of  its  bad  effects.  But  it  was  not  difficult  to  trace  a 
large  amount  of  direct  and  indirect  mortality  to  this  pernicious  custom.  Among 
childi'en  the  administration  of  opiates,  under  the  names  of  quieters  and  soothers,  is 
nearly  as  destructive  to  health  as  the  excessive  use  of  alcoholic  stimulants  among 
adults.  The  craving  for  both  arises  from  those  depressing  physical  causes  of  disease 
which  abound  in  cities." — Dr.  Lyon  Playfair,  On  Sanitary  Reform,  Social  Science 
Congress,  Glasgow,  Oct.  3d,  1874.^ 

4 


50  DISEASES   OF   CHILDRElSr. 

requires  to  be  given  with  the  utmost  caution.  In  administering 
tincture  of  opium  by  the  mouth  it  is  well  to  observe  the  rule  of 
giving  the  sixth  or  fourth  of  a  drop  to  an  infant  under  three 
months,  and  to  repeat  it  as  occasion  may  require;  half  a  drop  for 
a  child  of  six  months,  and  a  full  drop  for  a  year,  adding  a  drop  for 
every  year  of  the  child's  age.  I  once  prescribed  six  minims  in  an 
ounce  and  a  half  of  demulcent  mixture  for  a  child  fourteen  weeks 
old,  one  teaspoonful  to  be  given  three  times  a  day.  This  was 
enough  to  make  it  so  sleepy  and  heavy,  that  the  mother  said  she 
could  not  keep  it  awake.  When  roused,  it  opened  its  eyes,  and 
then  fell  off  to  sleep  again.  Instead  of  having  six  motions  during 
the  day,  it  had  three.  Fortunately  we  can  often  get  on  without 
the  internal  exhibition  of  laudanum,  which  is  a  remedy  we  regard 
as  certainly  dangerous  to  young  children  if  incautiously  given. 
A  child  will,  however,  take  a  dose  of  calomel  with  far  greater 
impunity  than  an  adult,  and  be  infinitely  less  likely  to  run  any  risk 
from  salivation.  Bromide  of  potassium,  and  hydrate  of  chloral,  are 
now  recognized  to  be  of  great  value  in  the  treatment  of  children's 
diseases. 

To  sum  rp  these  points,  it  is  to  be  observed  that  I  have  laid 
stress — 

1.  On  the  peculiar  forms  which  disease  assumes  in  childhood, 

as  distinguished  from  the  forms  of  the  same  disease 
prevalent  in  adults  ; 

2.  On  the  rapidity  with  which  functional  sometimes  passes 

into  organic  mischief,  during  the  period  of  bodily  and 
mental  development ;  so  that  no  ailment  should  be  con- 
sidered too  trivial  to  receive  attention  ; 

3.  On  the  great  importance  of  looking  to  constitutional  symp- 

toms rather  than  to  local  derangements,  because  the 
primary  disturbance  may  be  of  greater  moment  than 
the  secondary  eflects ; 

4.  On  the  necessity  of  looking   to   diet,  and   adapting   the 

quality  and  quantity  of  the  food  to  the  age  and  natural 
strength  of  the  child  ; 
6.  On  the  importance  of  selecting  medicines,  when  medicine 
is  absolutely  demanded,  from  that  class  which  will  sup- 
port the  bodily  powers  and  assist  in  maintaining  each 
function  as  nearly  as  possible  at  a  normal  standard. 

9 


ACUTE   AXD   CHRONIC   DISEASE.  51 

It  is  my  object  in  the  following  pages  to  carry  out  these  general 
principles,  and  to  show  how  they  are  to  be  adapted  to  particular 
diseases,  and  what  exceptional  treatment  each  disease  seems  to 
warrant. 


CHAPTER    III. 

ACUTE    ASB    CHRONIC    DISEASE. 


Importance  of  distinguishing  between  acute  and  chronic  disease — Acute  diseases  brief  in 
their  duration — Chronic  diseases  sloic  in  their  progress — Illustrations  of  both  forms — 
Collapse — Asphyxia — Hcemorrhage.  Treatmext  of  Acute  Disease  :  To  endeavor 
to  prevent  its  passing  into  the  chronic  form —  Use  of  alcohol — Emetics — Purgatives — 
Inhalations.  Treatment  of  Chronic  Disease  :  To  be  guided  by  its  duration, 
and  the  character  of  the  constitution,  whether  strumous,  syphilitic,  or  cachectic — Im- 
portance of  rest  and  fostering  physical  growth — Country  residence — Sea  air. 

Diseases  may  be  advantageously  divided  into  two  great  classes, 
the  acute  and  the  chronic.  Although  we  recognize  a  connection 
between  them  and  an  interdependence,  there  exists,  notwithstand- 
ing, a  wide  difference.  The  importance  of  defining  the  line  of 
demarcation  cannot  be  over  estimated.  Between  the  duration  of 
acute  and  chronic  disease  there  is  another  distinction.  An  acute 
disease  like  haemorrhage  or  cholera  may  terminate  in  a  few  days 
or  hours,  whilst  a  chronic  disorder,  as  asthma  or  rheumatism, 
may  continue  through  the  greater  part  of  life.  An  acute  disease 
is,  so  to  speak,  an  emergency,  and  immediate  measures  are  neces- 
sary to  meet  it.  Chronic  disease  being,  by  its  very  definition, 
slow  in  its  progress,  gives  us  time  to  consider  ;  during  which  time 
emergencies  may  arise  of  a  character  generally  but  not  always  to 
be  described  as  subacute.  The  management  of  the  acute  is  com- 
paratively simple,  the  management  of  the  chronic  is  often  a  com- 
plex affair.  There  is  the  treatment  both  of  the  chronic  condition 
and  the  difterent  intercurrent  maladies  which  arise  in  its  course. 
Since  these  secondary  maladies  are  often  more  prominent  than  the 
chronic  morbid  mischief  which  underlies  them,  the  primary  state 
may  be  overlooked.  The  character  of  the  disease  itself  gives  the 
main  lines  by  which  we  must  travel,  and  which  may  be  fairly 
clear  ;  but  when  secondary  complications  arise,  they  furnish  con- 
tingencies -which  tax  to  the  utmost  alike  our  acquired  knowledge 
and  our  individual  skill.    'This  involves  the  true  comprehension, 


62  DISEASES   OF   CHILDREN. 

not  only  of  the  acute  miscliief,  but  also  of  the  chronic  condition 
which  lies  beneath  and  influences  it.  An  apparently  simple 
inflammation  of  a  joint  in  a  healthy  child  becomes  a  wonderfully 
diflierent  condition  in  a  child  who  is  naturally  strumous ;  so  that 
the  state  of  constitution  has  to  be  recognized  in  every  child, 
whether  its  ailment  be  acute  or  chronic.  Indeed,  constitutional 
debility  and  the  strumous  and  syphilitic  diatheses  are  practically 
chronic  diseases.  The  manner  in  which  they  influence  complica- 
tions is  only  too  well  known  ;  and  the  fatal  result  of  a  simple  acute 
affection,  not  in  itself  severe,  may  be  entirely  due  to  some  chronic 
morbid  condition  underlying  it. 

The  terms  acute  and  chronic  are,  after  all,  somewhat  arbitrary. 
They  seem  to  imply  two  sets  of  diseases  perfectly  distinct,  and 
having  no  exact  relation  the  one  with  the  other ;  but  in  reality 
there  are  intermediate  stages  or  degrees  of  disease  which  these 
two  terms  do  not  include.  Subacute  is  a  term  used  to  signify  the 
duration  of  disease  when  it  is  neither  actually  acute  nor  chronic, 
but  something  between  the  two — a  relic  of  the  acute  affection, 
with  a  duration  shorter  than  the  chronic. 

Indeed,  acute  and  chronic  are  terms  used  as  much  to  convey  an 
idea  of  the  duration  of  the  morbid  affection  as  of  its  intensity. 
Diseases  called  by  either  name,  may  belong  essentially  to  the  same 
great  family.  Acute  pneumonia  may  become  chronic  pneumonia, 
acute  pericarditis  chronic  pericarditis,  acute  rheumatism  chronic 
rheumatism,  and  acute  nephritis  may  terminate  in  the  chronic 
form  with  albuminuria.  Many  other  illustrations  might  be  fur- 
nished. "In  a  general  way,  we  call  diseases  that  spring  up  in  the 
system  suddenly,  or  in  a  brief  space  of  time,  or  that  are  rapid  in 
developing  their  characteristic  phenomena,  or  are  of  short  dura- 
tion, acute ;  and  those  which  have  the  reverse  characteristics  of 
slowness  of  increasing,  mildness  of  manifestation,  and  longness  of 
duration,  chronic.  These  distinctions,  however,  are  obviously  not 
.  of  an  essential  or  fundamental  kind,  as  they  have  reference  not  to 
the  nature  of  the  phenomena  so  much  as  to  the  mode  of  their 
manifestation  and  their  degree.  Indeed,  nearly  all  the  diseases 
termed  acute  present  themselves  in  the  chronic  form;  so  that  we 
may  almost  say  that  we  have  two  marked  varieties  under  every 
individual  nominal  diseace,  namely,  an  acute  and  a  chronic 
variety."* 

*  Nature  and  Art  in  the  Cure  of  Disease,  by  Sir  John  Forbes,  1857,  p.  62. 


ACUTE  AND   CHRONIC   DISEASE.  53 

Some  loml  diseases  are  essentially  of  a  chronic  character,  as  the 
"usual  forms  of  hip  joint  disease  and  mesenteric  disease;  the  cir- 
culation is  depressed  and  low,  and  changes  proceed  slowly  ;  whilst 
in  many  constitutional  diseases,  as  fevers,  inliammations,  etc.,  the 
tendency  is,  to  produce  lesions  and  such  changes  in  the  secreting 
functions  of  organs  that  they  become  temporarily  or  permanently 
deranged,  and  health  does  not  return  till  the  natural  secretions 
are  once  again  restored,  and  the  parts  involved  have  resumed  their 
normal  state. 

The  term  acute  may  be  applied  to  a  class  of  affections  which  are 
largely  inflammatory  or  zymotic,  including  the  whole  list  of  febrile 
and  eruptive  diseases.  The  condition  may  also  arise  from  severe 
shock  as  after  surgical  operations,  and  the  patient  may  actually 
sink  in  consequence,  or  it  may  be  caused  by  exposure  to  great  heat 
or  cold,  or  sudden  and  severe  prostration,  as  in  bronchitis  during 
winter ;  or  in  the  severe  gastric  disturbance  caused  by  the  pres- 
ence of  indigestible  food  in  the  stomach. 

First,  as  regards  pyretic  affections.  The  rapidity  with  which 
the  rise  of  temperature  comes  on  is  in  itself  instructive.  "Where 
the  evidences  of  any  acute  specific  disease  are  wanting,  and  there 
are  no  obvious  lesions  to  account  for  the  rise  of  temperature,  the 
practitioner  is  apt  to  assume  that  he  has  got  a  case  of  typhoid 
fever  to  deal  with.  The  oncome  of  typhoid,  however,  is  usually 
insidious,  and  a  period  of  prostration  precedes  the  pyrexia.  But 
it  is  so  in  some  other  diseases.  It  is  so  in  nearly  all  diseases 
marked  by  a  period  of  incubation,  though  not  in  all ;  for  a  child 
may  be  exposed  to  the  infection  of  scarlet  fever,  and  feel  quite 
well  till  a  sudden  rise  of  temperature  comes  on.  Thus,  I  have 
known  a  child  convalescent  from  pneumonia  with  a  normal  tem- 
perature at  9  A.M.,  get  a  rise  of  four  degrees  at  1  p.m.,  and  forth- 
with symptoms  of  scarlet  fever  to  be  developed,  passing  regularly 
through  each  succeeding  stage.  The  premonitory  symptoms  of 
typhoid  fever  are  not  sufficiently  well  marked  to  enable  us  always 
to  foretell  what  is  in  store  for  us.  The  absence  of  one  symptom 
alone  may  be  embarrassing,  because  it  renders  incomplete  the 
chain  of  evidence  we  require  to  establish  our  diagnosis — there  is 
a  missing  link.  We  have  often  to  wait  for  some  days,  say  eight 
or  ten,  till  fever-spots  have  appeared,  or  there  is  such  a  combina- 
tion of  symptoms,  as  elevation  of  temperature,  quick  pulse,  diar- 
rhcea,  and  tympanites,  which  leave  no  doubt  as  to  the  nature  of 


54  DISEASES    OF    CHILDEEX. 

the  case.     "Whereas,  on  the  other  hand,  acute  indigestion  is  essen- 
tiall}^  a  very  acute  disease ;  the  rise  of  temperature,  of  pulse  and 
respiration,  being  exceedingly  rapid  in  young  subjects.   This  very 
rapidity  in  itself  should  put  the  practitioner  on  his  guard ;  such 
rapid  rise  in  temperature,  pulse,  and  respiration,  is  very  rarely 
seen  except  in  catarrhal  conditions  attacking  children  of  highly 
nervous  temperament.     In  these  children  the  different  nervous 
centres  are  highly  mobile  and  unstable,  and  great  perturbations 
are  readily  excited  by  slight  provoking  causes.     To  this  subject 
we  will  refer  further  on.    The  same  holds  good  of  rapid  variations 
in  the  pulse.     A  very  rapid  pulse  quickly  produced  is  suggestive 
rather  of  a  fright  or  start  than  of  any  actual  lesion.     What  has 
been  said  of  the  temperature  and  pulse  holds  good  of  the  respira- 
tion, but  a  great  inequality  between  the  two  is  of  ill  omen,  a  rapid 
pulse  with  slow  respiration  denoting  a  grave  condition.     I  may 
here  observe  that  children  in- whom  the  neurosal  temperament  is 
highly  marked  are  exceedingly  liable  to  disturbances  in  their 
health,  and  to  fluctuations  in  temperature.     I  may  quote  one  in- 
stance among  many.     A  child  is  excitable,  nervous,  and  weak ; 
one  of  those  restless  children  that  are  never  still.     It  contracts  a 
Blight  catarrh,  and  the  only  physical  sign  of  the  mischief  is  a 
little  alteration  in  the  breathing;  but  dulness  is  nowhere  to  be 
detected.     A  ny  agitation  excites  cough  of  a  spasmodic  or  irritable 
character,  and  sleep  is  restless  and  disturbed.    The  pulse  is  quick, 
the  respiration  hurried,  the  countenance  is  placid  ;  the  tempera- 
ture in  the  evening  runs  up  to  103°  or  more,  and  falls  in  the  morn- 
ing, perhaps  for  a  few  days,  to  101°  or  100°,  and  then  resumes  its 
normal  state.     If  the  child  so  attacked  was  not  of  this  neurosal 
constitution,  slight  catarrh  would  not  send  up  the  temperature  in 
this  way,  or  manifestly  affect  the  constitution.     I  have  known 
several  instances  of  this  in  rickety  and  feeble  children  who  have 
Been  allowed  to  get  into  an  exhausted  condition.   In  such  children 
the  temperature  may  be  persistently  high  for  days  together  ;  the 
pulse  160,  and  respirations  60  to  80.     Yet  there  have  been  no 
physical  signs  to  account  for  it,  no  cough,  no  vomiting,  no  stupor. 
General  tuberculosis  is  sometimes  at  the  root  of  this  condition, 
but  in  other  cases  the  health  gradually  improves  and  the  symp- 
toms pass  off.* 

*  "The  physician  is  liable  to  be  misled  by  placing  too  much  reliance  on  the  phe- 
nomena of  temperature.     They  are  not  infrequently  interfered  with  by  complications 


ACUTE    AND    CHRONIC    DISEASE.  65 

We  have  other  instances  of  acute  diseases  in  children,  as  severe 
pain  from  abdominal  trouble,  colic,  gravel,  etc., — a  degree  of  pain 
which  may  even  produce  shock  and  unconsciousness. 

Acute  headache  is  very  ominous  in  a  young  child,  and  may  be 
the  commencement  of  meningitis  or  convulsions,  or  precede  pneu- 
monia, or  some  eruptive  disease. 

Collapse  is  an  acute  condition  brought  about  by  the  loss  of  blood 
or  violent  exertion,  by  intense  mental  excitement,  by  overpowering 
heat,  by  acute  diarrhoea,  by  the  excessive  use  of  stimulants,  and  by 
the  continuance  of  bronchitis  or  pneumonia,  which  has  so  affected 
the  nervous  centres  and  the  cardiac  ganglia  as  to  almost  paralyze 
them,  and  to  inferfere  or  even  arrest  the  normal  changes  in  the 
lungs.  In  the  latter  condition  I  have  known  the  cerebral  circula- 
tion so  damaged  as  to  lead  to  convulsions  and  death. 

When  a  large  quantity  of  blood  is  lost  by  hpemorrhage,  the  heart 
is  almost  paralyzed  in  its  movements  from  the  withdrawal  of  its 
normal  stimulus,  and  it  can  only  propel,  at  each  contraction,  a  small 
portion  of  blood — not  enough  to  sustain  the  vital  functions. 

Asphyxia,  again,  may  be  classed  as  an  acute  condition ;  it  is  a 
common  mode  of  death  in  many  diseases,  as  in  lai^yvgismus 
stridulus,  croup,  and  in  hronchopneumonia,  in  which  pus  and 
mucus  may  till  up  the  small  branches  of  the  air  tubes  and  cells,  so 
that  the  respiration  fails  and  the  heart  ceases  to  beat.  In  the  latter 
condition  we  have  recourse  to  poulticing,  and  the  free  administration 
of  stimulants  to  raise  the  faltering  circulation.  It  may  also  be 
induced  by  drinking  boiling  water  from  a  kettle,  or  from  getting 
a  bead  or  button  into  the  trachea. 

Again,  in  haemorrhage,  which  may  be  active  or  due  to  acute 
disease,  when  arising  from  the  rupture  of  an  artery  as  in  the  lung,. 

and  accidental  events.  As  an  illustration,  a  young  girl  had  passed  through  typhoid 
fever,  convalescence  being  declared  in  connection  with  other  symptoms,  by  the  laws  of 
thermometry  belonging  to  the  decline  of  fever  or  defervescence  in  this  disease.  Sud- 
denly hysterical  symptoms  were  manifested,  and  the  temperature  rose  to  105°.  The 
physician,  a  man  of  learning  and  larger  experience,  was  naturally  alarmed.  In  a  few 
hours,  however,  the  temperature  declined,  and  recovery  took  place  without  further 
impediment.  The  expressive  comment  made  by  the  physician  was,  '  This  is  not  the- 
first  time  I  have  been  fooled  by  temperature  ! '  With  regard  to  the  information  fur- 
nished by  the  thermometer,  as  well  as  other  diagnostic  symptoms,  it  is  to  be  borne  in 
mind  that  there  are  exceptions  to  rules  which  are  generally  applicable." — Austiit: 
Flint.  The  temperature  may  be  raised,  like  the  respiration  or  the  pulse,  by  excite- 
ment or  nervousness,  especially  in  delicate  girls  or  young  children  of  mobile  temper- 
ament. 


56  DISEASES   OP   CHILDREN. 

the  quality  of  the  blood  evacuated  and  the  symptoms  induced  are 
quite  different  from  the  passive  form  of  haemorrhage,  which  some- 
times takes  place  from  the  stomach  and  bowels,  or  from  the  kidneys 
where  the  blood  has  become  thin  and  disorganized  by  some  poison, 
as  that  of  typhoid  fever :  it  is  a  state  allied  to  congestion  in  its 
early  stages,  when  the  smaller  vessels  become  large  and  rupture 
through  long-standing  debility,  or  some  impediment  to  the  pulmo- 
nary circulation  in  consequence  of  heart  disease.  For  the  manage- 
ment of  this  active  form  of  haemorrhage,  saline  aperients,  low  diet, 
tartarated  antimony,  and  the  most  absolute  rest  are  needed  ;  whilst 
in  passive  haemorrhage  we  should  have  recourse  to  the  mineral  acids? 
tannic  or  gallic  acid,  or  even  astringent  forms  of  iron. 

Treatment  of  Acute  Disease. — The  chief  point  is  to  arrest  it  as 
quickly  as  possible,  so  that  it  may  not  run  into  a  chronic  form ; 
and  this  may  often  be  attained  when  the  case  comes  under  treat- 
ment early,  and  the  constitution  is  sound.  Hence  we  may  sometimes 
cut  short  acute  diseases  in  the  young  when  we  cannot  do  so  in  the 
old, because  in  the  latter,  there  is  not  only  the  constitutional  debility 
belonging  to  advancing  age,  but  tissue-change  also.  The  remedies 
we  employ  are  as  a  rule  (at  least  at  an  early  stage)  antiphlogistic 
and  eliminative,  such  as  venesection,  and  the  use  of  calomel  and 
antimony.  In  the  violent  pain  of  acute  disease,  as  enteritis  or 
colic,  larger  doses  of  opium  are  borne  than  are  safe  under  ofher 
circumstances.  But  they  should  be  reduced  or  withheld  entirely 
as  soon  as  the  pain  ceases. 

To  approach  a  young  child  in  acute  disease  is  a  difficult  matter, 
and  requires  much  care  and  tact,  unless  it  is  so  ill  that  its  sensi- 
bilities are  blunted,  and  it  takes  no  notice  of  anything  that  is  going 
on.  To  examine  it,  to  feel  the  pulse,  to  listen  to  the  chest,  or  to 
look  into  the  throat,  are  wellnigh  impossible  in  some  cases,  and 
the  information  so  gained  is  at  such  a  cost  that  it  is  scarcely  worth 
possessing.  The  fretfulness  and  peevishness  of  some  children  is 
most  trying  to  contend  with  in  severe  cases.  The  children  put 
themselves  in  such  a  temper  by  obstinate  refusal  to  take  medicine, 
that  in  cases  where  coercion  has  to  be  used,  it  is  as  a  rule  better  to 
abandon  the  medicine,  at  least  for  a  time. 

With  regard  to  the  use  of  alcohol  in  acute  disease,  perhaps  there 
is  no  one  point  of  greater  importance  than  this.  Many  acute 
affections  in  young  children  may  be  conducted  safely  through  each 
;Btage  without  any  necessity  for  its  administration.     If  there  is 


ACUTE   AND   CHRONIC   DISEASE.  57 

cerebral  exhaustion  through  failing  circulation,  it  may  have  the 
effect  of  stimulating  the  cerebral  cells,  in  fact,  of  sending  more 
blood  to  the  brain, and  thus  tranquillizing  the  system  and  promoting 
sleep.  If,  however,  there  is  great  exhaustion,  and  the  stomach  is 
irritable,  and  cannot  retain  food,  gas  is  often  generated  and  disten- 
sion takes  place,  which  interferes  with  cardiac  movement.  Now, 
alcohol  Tinder  some  circumstances  is  clearly  indicated,  as  when 
there  is  great  excitability  and  restlessness,  high  temperature,  rapid 
pulse  and  respiration.  Here  a  full  dose  of  alcohol  will  often  pro- 
duce the  most  beneficial  effect.  It  is  as  useful  here  as  the  chronic 
use  of  it  in  imperfect  nutrition  is  to  be  deprecated. 

In  the  treatment  of  acute  disease  we  ought  not  to  traverse  but 
to  follow  Nature's  processes.  A  great  deal  may,  however,  be  done 
to  expedite  the  different  stages  of  the  malady.  In  acute  indiges- 
tion, for  instance,  w^here  the  child  vomits  and  subsequently  is 
purged,  the  attack  usually  wears  off  quickly.  Where  these  pro- 
cesses are  not  spontaneously  instituted,  we  can  usually  do  much 
good  by  administering  an  emetic,  with  a  grain  or  two  of  calomel, 
followed  in  two  or  three  hours  by  several  grains  of  jalap  or  scam- 
mony,  according  to  the  age  and  strength  of  the  child.  Also  in 
acute  catarrh,  a  dose  of  ipecacuanha  wine  with  a  few  drops  of 
antimonial  wine  will  often  shorten  the  whole  attack;  not  only  as 
to*  the  first  stage  of  vascular  turgeseence  and  dryness  of  the 
bronchial  lining  membrane,  but  also  that  of  the  secondarj''  stage 
of  free  secretion  and  expectoration,  especially  if  the  measures 
appropriate  to  that  stage  are  then  resorted  to.  These  measures 
are  stimulant  expectorants  and  tonics.  Probably  inhalations  of 
steam,  simple  or  medicated,  will  tend  to  shorten  both  stages.  In 
diarrhoea,  due  to  irritant  material  in  the  bowel  which  the  system 
is  itself  attempting  to  remove,  but  without  success,  a  few  grains 
of  rhubarb  by  its  first  action  as  a  purgative  Avill  effectually  dis- 
lodge the  irritant  matter ;  while  its  secondary  action  as  an  astring- 
ent tends  to  prevent  any  persisting  diarrhoea  so  set  up. 

Chronic  disease  may  take  on  an  acute  form  ;  it  may  assume 
acute  manifestations,  and  it  should  be  our  aim,  if  possible,  to  pre- 
vent this.  The  tendency  of  this  condition  is  to  produce  slow 
degenerative  changes,  and  death  from  failure  of  the  vital  powers.' 
In  chronic  affections  after  scarlet  fever  and  nephritis,  acute  symp- 
toms may  spring  up  indicating  pericarditis  or  pleurisy.  Bron- 
chitis, again,  of  an  acute  and  sometimes  of  a  subacute  character, 


58  DISEASES   OF   CHILDREN. 

frequently  comes  on  in  the  strumous  or  syphilitic  diathesis. 
Strumous  children  are  liable  to  suiter  from  acute  suppuration  of 
their  cervical  glands,  or  mischief  in  their  joints,  or  affections  of 
their  bones.  It  is  often  set  up  by  an  acute  malady,  or  by  a  period 
of  insufficient  food.  In  congenital  syphilis,  condylomata  or  syph- 
ilides  may  be  excited  by  some  intercurrent  cause,  notably  vaccina- 
tion, or  even  shock.  Both  in  syphilis  and  struma  we  may  have 
acute  periods  of  anaemia  and  malnutrition.  Under  these  circum- 
stances, if  the  child  be  exposed  to  the  poison  of  specific  disease  it 
vv^ill  most  likely  have  it  in  a  very  severe  form  of  an  asthenic  type- 
Or  a  family  of  children  v^nth  congenital  taint  may  be  at  the  sea- 
side when  two  or  three  days  of  severe  cold  may  be  experienced  ; 
one  child  of  the  number  has  bronchitis  or  pneumonia,  to  which  it 
may  succumb,  whilst  the  other  children  are  unaffected  by  the 
changes  of  temperature. 

Acute  disease  is  very  common  at  an  early  period  of  life ;  thus 
infants  are  often  carried  off  by  convulsions  when  there  exists  any 
derangement  of  the  alimentary  canal  through  feeble  digestion,  or 
improper  food.  "  Defective  nutrition  in  the  early  stages  of  life,  iu 
the  nursery,  unrecognized  by  those  who  have  the  management  of 
children,  is  the  probable  explanation  of  one  of  the  problems  of 
practice.  Healthy  parents,  still  young,  constitutionally  well  en- 
dowed, living  under  favorable  social  circumstances,  not  unfrequently 
have  children  who,  although  apparently  healthy  at  first,  sicken 
and  die  of  phthisis  and  of  other  diseases  as  they  grow  up."^ 

General  debility  or  uniform  depression  of  the  bodily  powers,  is 
a  chronic  disease  under  which  acute  disease  may  be  readily  ex- 
cited. In  this  chronic  state  we  have,  as  it  were,  to  steer  a  defec- 
tive ship  through  a  tempestuous  sea,  in  which  it  may  be  wrecked, 
unless  great  skill  and  judgment  are  exercised  in  its  management. 

Chronic  disease  is  exceedingly  fatal  in  more  than  one  way,  for 
either  imperfect  nutrition  of  tissues  having  begun,  the  disease 
goes  on  without  the  prospect  of  repair  for  an  indefinite  period, 
and  during  this  time  an  acute  disorder  is  very  likely  to  be 
awakened ;  or  if  not,  nutrition  gradually  fails,  and  death  takes 
place  sooner  or  later  from  exhaustion.  After  death,  pathological 
changes  present  themselves,  which  show  that  they  must  have  so 
impaired  the  vital  processes  as  to  render  the  constitution  very 
prone  to  fall  before  the  assault  of  any  acute  disorder. 

*  Nutrition  in  Ilealtli  and  Disease,  by  J.  11.  Bennett,  M.D.,  187G,  p.  227. 


ACUTE   AND   CHRONIC   DISEASE.  59 

Acute  disease,  then,  is  very  apt  to  supervene  on  chronic.  "When 
the  great  glandnlar  organs  of  the  body  are  impaired,  and  the 
liver  or  kidneys  are  diseased,  and  the  elimination  of  morbid  prod- 
ucts is  interfered  with,  there  is  in  the  one  case  the  absorption  of 
biliary  elements  into  the  blood,  and  in  the  other  the  retention  of 
urinary  ingredients  which  may  deprive  the  patient  of  life,  gradu- 
ually  or  rapidly. 

The  effects  of  deficient  or  improper  food  in  inviting  chronic 
disease  among  children  is  well  known,  and  the  evidence  is  over- 
whelming on  the  point.  The  careful  feeding  of  children  is  more 
important  than  their  education,  for  if  this  is  neglected  the  mental 
organization  must  suffer.  If  the  body  is  not  properly  nourished, 
the  brain  circulation  is  weakened,  and  the  intellectual  powers 
become  feeble  and  imperfectly  developed ;  they  do  not  acquire  the 
vio'or  of  the  robust  child  whose  digestive  functions  have  received 
attention,  and  plenty  of  good  food  has  been  given  at  proper  inter- 
vals during  the  day ;  robust  children  grow  and  thrive  better,  they 
accomplish  their  school-work  better,  and  they  obtain  more  re- 
freshing sleep.  I  have  repeatedly  seen  children  who  are  languid, 
weakly,  and  irritable,  with  such  a  history  as  the  following:  The 
last  meal  of  tea  and  bread-and-butter  is  given  about  five  or  six 
o'clock,  they  retire  to  bed  an  hour  or  two  later,  and  get  no  other 
nourishment  till  breakfast  next  morning.  The  consequence  is, 
that  in  three  hours  after  the  last  meal  they  are  drawing  on  their 
reserve,  the  stomach  is  empty,  and  they  are  so  exhausted  that 
they  begin  the  following  day  quite  unable  to  perform  its  duties 
properly.  Physical  and  intellectual  strain  are  both  ill-borne  at 
such  times. 

Deficient  animal  food  for  growing  children,  especially  boys  who 
follow  athletic  sports,  is  a  fearful  mistake  ;  a  farinaceous  diet  will 
not  supply  its  place.  Too  long  fasting  at  any  age  produces  ex- 
haustion, irritable  brain,  and  enfeebled  digestion  ;  the  appetite  be- 
comes impaired,  and  when  food  is  taken,  it  is  repugnant  and  dis- 
tasteful. Malnutrition  having  been  established,  anaemia,  general 
debility,  tuberculosis,  phthisis,  etc.,  are  gradually  and  certainly 
induced. 

Delicate  boj-s  often  refuse  to  eat  the  fat  of  butcher's  meat,  de- 
claring that  they  would  rather  take  cod-liver  oil.  Now  cod-liver 
oil  is  not  attractive  to  the  palate,  but  these  children  can  digest  it 


60  DISEASES   OF    CHILDEE^T. 

when  they  are  unequal  to  the  assimilation  of  the  other  animal 
fats. 

Treatment  of  Chronic  Disease. — This  is  altogether  different  from 
that  of  the  acute  form.  The  method  is  to  be  watchful ;  the  sen- 
tinel has  to  give  notice  of  an  attack,  rather  than  to  invite  it. 
The  position  is  one  of  defence.  If  our  treatment  is  to  be  success- 
ful we  must  be  guided  to  a  very  great  extent  by  the  character  and 
duration  of  the  disease,  as  well  as  the  constitution  of  the  patient 
and  his  hereditary  or  acquired  tendencies.  In  the  strumous  dia- 
thesis we  want  more  iron,  more  lime,  and  more  fat.  In  syphilis 
we  essentially  want  mercury.  In  cachectic  conditions  this  remedy 
should  be  combined  with  iron,  cod-liver  oil,  and  good  food.  In 
both  cases  pure  country  air  and  the  seaside  are  important.  In  a 
nervous  diathesis,  quiet,  avoidance  of  excitement,  and  little  school- 
work,  are  indicated.  In  a  bilious  child  the  great  point  is  to  look 
to  the  digestive  organs — not  to  allow  more  food  to  be  taken  than 
can  be  digested,  or  a  bilious  seizure  is  certain,  and  consequent  de- 
pression, which  renders  the  child  susceptible  to  all  external  influ- 
ences. 

Some  remedies  seem  to  bring  diseases  quickly  to  an  end,  notably 
in  chronic  disease ;  they  arrest  it,  and  prevent  the  next  stage  of 
tissue  change.  In  this  way  we  can  cure  ague  by  quinine  and  ar- 
senic ;  certain  skin  afiections,  as  itch,  by  sulphur  ;  and  sj^philis  by 
mercury ;  but  the  same  principle  does  not  hold  good  in  the  acute 
diseases,  which  terminate  of  themselves  in  recovery.  Thus  we  do 
not  actually  cure  typhoid  fever  or  the  exanthemata  ;  we  can  watch 
the  different  stages  of  the  special  malady,  and  sometimes  even 
prevent  complications,  or  render  them  milder ;  but  we  do  not  ac- 
tually cure  the  disease.  By  not  losing  sight  of  this  great  principle 
we  may  often  modify  and  render  milder  a  disease  which  might 
otherwise  be  virulent  and  fatal. 

How  important  it  is  that  in  many  chronic  affections  the  child 
should  sleep  thoroughly  so  as  to  get  plenty  of  rest,  the  value  of 
which  cannot  be  overestimated.  "The  value  of  rest  and  placidity 
in  fostering  the  generation  of  that  highly  organized  animal  tissue 
which  forms  so  large  a  portion  of  our  staple  food  is  well  known 
to  the  stockkeeper  and  grazier.  A  homely  illustration  may  be 
found  in  the  fact,  that  in  infancy  the  child  who  sleeps  much  mostly 
thrives  ;  and  mutatis  mutandis,  the  observation  is  equally  true, 
that  the  wakeful,  restless  child,  seldom  displays  the  evidence  of 


ACUTE   AND   CHRONIC   DISEASE.  61 

active  nutrition ;  and,  doubtless,  all  will  admit  that  in  infancy  de- 
velopment is  in  its  highest  state  of  activity,  and  that  the  healthy 
infant  passes  the  greater  portion  of  its  life  in  a  state  of  rest  and 
sleep.  Growth — the  renewal  of  some  parts,  and  the  fresh  devel- 
opment of  others,  seems  thus  to  claim  as  its  helpmates  sleep  and 
rest."* 

A  good  physical  development  is  the  first  thing  to  be  aimed  at. 
The  quick,  bright,  intelligent,  but  slight  town  child,  the  delight 
of  its  parents  and  their  friends,  does  not  possess  the  potentialities 
of  the  strong,  bulky,  slow-witted,  often  loutish-looking  child,  we 
see  in  the  country.  The  one  is  eating  its  cake,  is  living  its  life, 
the  other  is  storing  up  force.  Slow,  apparently  indeed  dilatory, 
comes  the  intellectual  development  of  the  typical  country  child ; 
but  its  potentialities  are  far  beyond  those  of  the  other  child.  In 
"Westmoreland  this  fact  of  slow  developjment  is  recognized  in 
the  saying  that  "Westmoreland  lads  have  no  sense  till  they  are 
twenty-one." 

There  is  a  direct  antagonism  between  mental  precocity  and 
physical  growth.  ^Yith  these  facts  before  us  it  is  quite  clear  that 
where  we  have  bright,  quick  town  children,  with  a  defective 
phj'sique,  a  small  thorax,  and  a  flat  abdomen,  it  becomes  emi- 
nently desirable  to  develop  a  totally  different  condition.  Xo  mat- 
ter at  what  cost  to  their  immediate  prospects  these  children  should 
be  sent  into  the  country  to  grow  into  healthy  animals.  The  more 
marked  the  characteristics  of  town  birth,  the  more  necessary  is  it 
to  adopt  such  a  plan.  If  permanent  life  in  the  country  for  several 
years  is  not  attainable,  a  month  in  spring,  and  two  or  better  three 
months  in  autumn,  should  be  spent  in  the  country.  The  duller, 
the  quieter,  the  less  exciting  the  country  residence  the  better  for 
strumous  children.  For  very  delicate  children,  it  may  be  advis- 
able for  the  spring  months  to  select  a  warm  and  comparatively 
low-lying  sea-residence.  In  the  autumn,  however,  it  is  well  to 
choose  a  place  where  the  air  is  bracing,  if  by  the  seaside,  where 
there  are  downs ;  in  the  country,  where  there  are  hills.  The  more 
nearly  the  life  then  led  approaches  that  of  the  ordinary  country 
child  the  better.  After  a  substantial  breakfast  the  children  should 
be  sent  out  for  a  walk ;  if  at  the  seaside,  where  they  must  take 
a  bath,  this  walk  should  not  be  too  Ions;,  so  as  not  to  exhaust 

*  On  Pain  and  the  Therapeutic  Influence  of  Mechanical  and  Physiological  Eest, 

etc.,  by  J.  Hilton,  F.R.S.,  The  Lancet,  1860,  vol.  ii,  p.  103. 


62  DISEASES   OF   CHILDREN. 

them  before  takins;  it.  A  child  should  never  take  a  bath  in  the 
sea  in  a  condition  at  all  approaching  exhaustion.  If  an  inland 
residence  is  preferred,  the  walk  may  be  made  longer,  provided  it 
does  not  go  to  the  length  of  fatigue  and  loss  of  appetite.  The 
midday  meal  should  be  substantial,  and  there  is  no  objection  to  a 
sleep  after  it,  especially  if  the  child  feels  drowsy.  A  prejudice 
prevails  against  sleeping  in  the  day,  which  is  by  some  persons  car- 
ried to  extremes.  The  intention  is  that  the  child  shall  eat,  sleep, 
and  grow.  If  such  treatment  of  town  children  were  more  thor- 
oughly carried  out,  we  should  hear  less  of  imperfect  physiques,  of 
an  early  breakdown  after  much  precociousness ;  and  town  chil- 
dren would,  so  treated,  approach  more  closely  to  those  reared  in 
the  country.  Precocity  is  eminently  undesirable,  and,  if  possible, 
to  be  avoided. 

We  must,  too,  never  overlook  the  fact,  that  acute  and  chronic 
disease  with  their  complications,  depend  upon  a  variety  of  influ- 
ences and  associations.  The  anatomical  relations  may  guide  func- 
tional complications,  and  even  determine  lesions  of  structure.  The 
scrofulous,  the  rheumatic,  and  the  anaemic  states,  severallj^  influ- 
ence the  liability  of  certain  organs  to  suft'er  in  different  ways,  be- 
cause the  state  of  the  secretions,  the  degree  of  vascularity,  and 
the  morbid  changes  of  the  blood,  dispose  to  diseased  action. 
Vital  resistance  is  as  great  in  the  strong  as  it  is  defective  in  the 
delicate. 


CHAPTER  IV. 


DEBILITY. 

Definition — Symptoms  and  treatment — Liability  to  lead  to  organic  disease. 

Under  the  head  of  debility  in  children,  or  constitutional  de- 
pression, I  shall  enumerate  a  group  of  symptoms  which  is  very 
commonly  met  with,  especially  among  the  out-patients  of  our 
hospitals.  It  is  a  condition  sometimes  the  forerunner  of  disease, 
and  then  the  signs  which  characterize  this  altered  health  are  lost  in 
the  disease  which  springs  up.  I  think  I  am  justified  in  attributing 
importance  to  this  condition,,  under  the  title  or  designation  of 


DEBiyXY.  63 

debility ;  for  promptly  recognized,  it  assists  us  to  attach  significance 
and  weight  to  the  earliest  indications  of  a  departure  from  the 
normal  standard  of  health. 

By  debility,  I  mean  functional  impairment,  atony,  weakness,  or 
preternatural  slowness  in  the  performance  or  working  of  the  vital 
processes,  leading,  when  neglected  or  overlooked,  to  debility  (and  it 
may  be  to  structural  change)  in  one  or  more  of  the  great  central 
organs  of  life  or  tissues  of  the  body.  This  may  be  considered  by 
some  as  involving  an  unnecessary  addition  to  our  medical  nomen- 
clature; but  debility  or  weakness,  as  commonly  employed,  is  used 
to  indicate  symptoms  attendant  on  various  diseases,  and  has  no 
isolated  and  individual  recognition  that  seems  to  me  commensurate 
Avith  its  importance. 

The  loss  of  blood,  or  free  purgation,  or  deficient  food,  or  any 
causes  that  reduce  the  vital  powers  of  the  j)atieut,  will  induce 
debility  in  a  simple  and  uncomplicated  form — a  deviation  from  that 
equalized  condition  of  all  the  bodily  and  mental  functions  we  term 
health.  As  the  constitution  tardily  recovers  from  the  shock  it  has 
sustained  the  functions  of  the  vital  organs  are  sluggishly  carried 
on,  and  if  repair  is  not  uniform  in  all  of  them,  the  balance  is  dis- 
turbed, and  after  some  hesitancy  disease  breaks  out  where  Ave 
least  expected  it.  In  our  earh^  contact  with  some  forms  of  illness 
we  are  unable  to  make  any  other  diagnosis  than  that  of  debility. 

When  symptoms  referable  to  one  organ  more  than  to  another 
become  apparent,  we  leave  a  general  plan  of  treatment  for  that 
which  is  determined  of  the  prevailing  symptoms.  When  it  has 
reached  this  stage  or  change,  the  debility  I  am  attempting  to 
describe  has  no  longer  an  independent  existence. 

I  claim  for  this  a  separate  and  special  classification  among  the 
ailments  of  children,  where  debility  is  observed  in  its  purest  and 
unmasked  form,  before  degenerative  lesions  are  conmion,  as  in 
after  life,  to  account  for  failing  strength,  increasing  debility,  and 
structural  alteration. 

There  are  very  well-defined  symptoms  belonging  to  this  state, 
alike  in  many  instances,  and  varying  in  extent  and  character  in 
others,  the  debility  being  a  marked  feature  of  the  complaint 
throughout.  There  is  powerlessness  and  lassitude  of  the  whole 
system ;  every  function  may  be  said  to  have  received  a  shock  ;  a 
temporary  pause  in  the  uniform  working  of  the  bodily  functions 
has  taken  place.    The  child  does  not  usually  complain  of  anything, 


Gl  DISEASES   OF   CHILDREN. 

but  hangs  and  droops  about,  and  ceases  to  take  an  interest  in  bis 
amusements.  The  vivacity  of  childhood  has  departed ;  in  some 
cases  he  has  a  shy  and  timid  look,  is  afraid  of  your  approach,  and  cries 
without  provocation.  In  most  cases  there  is  neither  discomfort  nor 
pain  ;  the  bowels  are  said  to  be  regular,  but  the  evacuations  are 
scanty  from  the  small  amount  of  food  that  is  taken.  On  inquiry 
we  shall  generally  find  that  the  bowels  act  sometimes  every  day, 
and  sometimes  once  in  two  or  three  days.  Among  private  patients, 
where  there  is  no  difficulty  in  testing  the  statement,  I  have  been 
led  to  regard  the  latter  period  as  the  most  common.  The  tongue 
is  clean  and  moist,  it  may  be  pallid,  but  indicates  no  active  dis- 
turbance. Very  frequently  there  is  a  film  on  the  tongue  of  a  thin 
silvery  whiteness,  or  the  coating  is  thicker  and  yellowish,  but  the 
front  of  the  tongue  is  nev^er  involved,  the  tip  and  sides  showing  a 
natural  hue.  Sometimes  it  presents  a  smooth  and  dusky  aspect,  as 
we  might  expect  in  a  languid  state  of  the  circulation.  The  pulse 
is  weak,  small,  and  usually  slow ;  sometimes  it  is  rather  accelerated, 
but  this  is  owing  to  the  agitation  and  nervous  excitement  so 
readily  induced  by  the  examination.  The  thermometer  indicates 
no  elevation  in  temperature.  On  the  other  hand  the  skin  often 
feels  very  cool,  and  the  mother  tells  j^ou  that  her  child  does  not 
take  sufficient  exercise  to  keep  him  warm.  He  is  often  noticed  to 
be  lying  across  a  chair  or  sofa  in  a  passive  state  of  indifference, 
dropping  off  into  a  calm,  quiet,  and  prolonged  sleep.  It  is  the  quiet 
sleep  of  fatigue,  and  not  the  restless  sleep  of  exhaustion.  If 
awakened  he  readily  falls  off  to  sleep  again,  and  is  glad  to  go 
to  bed  early,  when  the  same  drowsy  sleep  returns  and  lasts  till 
morning. 

In  April,  1869,  a  lady  brought  to  me  her  little  girl,  four  years 
of  age,  who  was  a  very  intelligent  and  pleasing  child.  I  was  left 
to  find  out  her  ailment  as  w^ell  as  I  could,  her  mother  saying  "  she 
really  did  not  know  what  was  the  matter  with  her,  but  she  was 
certain  she  was  not  well."  When  a  year  old  the  child  suffered 
from  palpitation,  and  two  years  afterwards  she  had  whooping- 
cough.  She  appeared  well  till  eight  weeks  before  I  saw  her,  since 
which  time  she  had  been  ailing  in  health.  She  was  said  to  be 
"  very  languid,  constantly  yawning,  and  wishing  to  go  to  bed  early 
in  the  day."  Her  face  flushed  on  being  asked  a  question,  and 
when  a  stethoscope  was  applied  to  her  chest  she  burst  into  a  fit  of 
tears,  which  her  mother  said  was  not  natural  to  her;  the  tongue 


DEBILITY.  65 

was  furred  at  the  back,  and  the  urine  was  rather  high-colored  ; 
the  lower  eyelids  were  dark,  and  the  expression  languid,  but  no 
complaint  whatever  was  made  of  pain ;  the  bowels  were  rather 
confined.  I  advised  that  the  child  should  be  tempted  to  take 
nourishment  frequently,  milk  and  eggs  being  given  in  the  way 
that  were  most  agreeable  to  her.  She  was  not  to  suffer  fatigue 
from  running  about,  but  to  be  driven  in  an  open  carriage  when 
the  weather  was  fine,  or  to  be  wheeled  about  the  garden.  Ape- 
rient medicine  was  strictly  forbidden.  Thirty  minims  of  the  Syr. 
Ferri  Phosp.  Comp.  in  two  teaspoonfuls  of  water  were  ordered 
three  times  a  day.  Improvement  soon  set  in,  and  on  the  12th  of 
May  she  had  nearly  recovered  her  usual  activity,  the  appetite  had 
returned,  the  tongue  was  quite  clean,  and  the  bowels  acted  regu- 
larly every  day. 

A  careful  physical  examination  in  these  cases  reveals  nothing 
important  about  the  chest  or  abdomen.  The  two  most  common 
attendant  symptoms  are  headache  and  pain  at  the  epigastrium, 
both  being  signs  of  debility  in  the  brain  and  stomach  respectively. 
So  far  as  we  can  learn,  the  headache  seems  to  be  a  heavy  oppres- 
sive weight  across  the  centre  of  the  forehead,  and  it  is  very  per- 
sistent, giving  the  child  a  dull  and  painful  appearance.  In  many 
of  these  cases  the  aspect  is  desponding  and  inanimate,  and  the 
cheerful  expression  of  childhood  has  vanished  ;  the  eyes  are  heavy 
and  have  a  hollow  look,  but  there  is  nothing  approaching  intoler- 
ance of  light,  nor  squinting,  as  we  observe  in  threatening  cerebral 
disease,  though  it  is  not  to  be  forgotten  that  the  brain  may  be  in- 
volved if  these  symptoms  are  allowed  to  go  on  without  treatment. 
The  pain  in  the  stomach  is  of  the  same  dull  aching  character, 
rather  discomfort  than  actual  pain,  and  is  limited  to  the  root  of 
the  ensiform  cartilage  or  its  immediate  vicinity.  It  is  the  uneasi- 
ness of  slight  gastralgia,  or  the  gnawing  sensation  we  have  all 
experienced  when  the  stomach  is  empty,  and  we  are  waiting  for  a 
meal  to  appease  it. 

There  may  be  aching  of  the  limbs,  muscular  fatigue,  and  pain 
in  the  course  of  the  spine. 

The  sj' mpathetic  system  shares  in  the  general  constitutional  de- 
pression, and  is  reduced  below  its  normal  standard.  The  appetite 
required  to  insure  the  perfect  digestion  and  assimilation  of  food 
and  nourishment  is  impaired,  and  the  emotions  are  susceptible  and. 
heightened  to  a  degree  which  readily  excites  disturbance  of  both. 

5 


66  DISEASES   OF   CHILDREN. 

mind  and  body.  The  face  may  change  from  the  pallor  it  exhibits 
in  repose,  to  frequent  blushing,  and  there  may  be  palpitation  of 
the  heart,  all  induced  by  slight  correction- or  fatigue,  or  the  over- 
taxhig  of  the  digestive  functions  even  with  the  ordinary  diet  of 
health,  when  half  paralyzed  by  fear  or  emotional  excitement. 

There  is  no  very  striking  symptom  which  indicates  this  derange- 
ment in  the  health.  It  is  to  the  totality  of  them  we  must  look 
for  a  diagnosis.  This  must  be  arrived  at  by  a  careful  process  of 
exclusion.  The  indications  of  the  disease  are  negative,  and  it  is 
the  failure  in  the  discovery  of  any  specific  cause  for  the  debility 
which  indicates  its  pure  and  uncomplicated  character.  There  is 
nothing,  so  to  speak,  that  is  apparent  or  tangible,  and  hence  it  is 
that  a  depraved  state  of  health  creeps  on  unnoticed,  and  is  not 
discovered  till  some  very  prominent  symptom  arrests  attention. 
There  is  no  cardiac  affection. 

Such  cases  as  these  make  us  cautious  in  giving  an  opinion.  In 
the  absence  of  any  discoverable  disease,  we  are  doubtful  whether 
this  unaccountable  debility  may  not  be  the  harbinger  of  mischief 
to  start  up  hereafter.  Disease  may  be  hidden,  to  come  forth  by 
and  by.  In  the  diseases  of  adult  life,  a  cause  is  often  discovered. 
iVot  so  in  the  cases  I  am  describing ;  the  debility  is  uncomplicated, 
and  it  must  be  seen  and  treated  before  it  has  merged  into  actual 
disease. 

These  cases  usually  terminate  well  if  promptly  and  skilfully 
treated,  but  a  continuance  of  this  condition  may  lead  to  pro- 
tracted disease,  and  subsequently  to  death.  For  example,  deficient 
nervous  power,  as  shown  by  headache,  may  lead  to  cerebral  ex- 
haustion, and  to  coma  and  convulsions,  in  the  same  manner  that 
congestion  and  inflammation  of  the  brain  may  terminate.  These 
are  opposite  states  of  the  system,  leading  to  the  same  consequences, 
but  requiring  a  different  mode  of  management. 

The  weak  and  enfeebled  stomach  of  young  children,  causing 
instant  rejection  of  food  by  vomiting,  is  often  checked  by  a  simple 
tonic,  and  sympathy  is  so  strong  with  the  cerebral  functions,  that 
when  the  stomach  has  recovered  its  power,  the  brain  is  lulled  into 
quietude.  If  it  did  not  so  yield  to  treatment,  the  symptoms 
would  pass  on  and  implicate  the  brain  in  the  manner  just  de- 
scribed. To  equalize  all  the  forces  of  the  body  is  the  surest  method 
•  of  maintaining  its  efficient  working.  It  is  the  loss  in  either  that 
.invites  disease. 


DENTITION.  67 

When  the  debility  has  weakened  the  digestive  and  nervous 
functions,  and  induced  loss  of  appetite,  muscular  pains,  deficient 
and  high-colored  urine,  and  torpid  bowels,  a  plan  of  treatment 
the  opposite  of  that  which  is  stimulating  and  generous,  may  suf- 
fice to  bring  about  a  return  of  strength  and  animated  feeling. 

These  cases  of  pure  and  simple  debility,  when  neglected,  cause 
chorea,  epilepsy,  convulsions,  paralysis,  etc.,  and  finally  lead  to 
those  changes  in  the  blood  which  originate  aneemia,  tuberculosis, 
and  every  form  of  diathesis  that  lowers  health  and  provokes 
disease. 


CHAPTER  Y. 

DENTITION. 


Symptoms  :  In  healthy  children  there  is  often  an  absence  of  suffering — In  the  rickety  and 
delicate,  abdominal  or  cerebral  disease  may  spring  up — Temporary  and  permanent  teeth 
— Order  of  their  appearance — Diarrhoea — Convulsions — Eczematous  affections  of  the 
skin.  Causes  of  Difficult  Dentition  :  The  rickety  constitution —  Vaccination. 
Treatment  :  Depends  upon  the  strength  and  constitution — The  strong  and  vigorous 
to  be  treated  differently  from  the  fesble  and  rickety — Aperients — Carminatives,  bromide 
and  iodide  of  potassium,  hydrate  of  chloral — Lancing  the  gums — Care  in  diet. 

Dentition  is  a  subject  which  requires  careful  consideration,  for 
it  is  important  that  we  should  form  definite  ideas  concerning  the 
part  it  plays  in  affecting  the  health  and  exciting  convulsive  and 
other  diseases.  Whilst  the  dangers  of  dentition  have  undoubt- 
edly been  exaggerated  by  some  authorities,  and  the  friends  of  the 
child  are  apt  to  become  anxious  during  this  period,  there  is,  it 
must  be  remembered,  a  real  degree  of  risk  in  certain  tempera- 
ments. Every  thoughtful  practitioner  ought  to  be  on  the  watch 
for  indications  of  disease,  which  the  process  of  teething  is  capable 
of  exciting. 

In  perfectly  healthy  children  the  teeth  appear  one  by  one  in 
regular  succession  with  little  or  scarcely  any  suffering ;  in  other 
instances,  as  in  the  rickety,  their  advent  is  contemporaneous  with 
the  commencement  of  delicate  health  ;  and  in  another  class  they 
are  the  harbingers  of  abdominal  or  cerebral  mischief.  The  evolu- 
tion of  the  teeth  tests  the  vigor  of  the  child,  and  the  more  tardy 
and  lingering  the  process,  the  less  is  its  strength  and  vitality. 


68  DISEASES    OF    CHILDREN. 

The  teeth  begin  to  appear  in  healthy  children  between  the 
seventh  and  eighth  month,  and  the  process  is  completed  between 
the  twenty-fourth  and  thirtieth  month.*  The  two  middle  or 
central  incisors  in  the  lower  jaw  first  appear  ;  then  in  the  coarse 
of  a  week  or  two  the  two  middle  incisors  in  the  upper  jaw ;  next 
come  in  another  month  or  six  weeks  the  two  lateral  incisors  in 
the  upper  jaw,  followed  by  the  two  lateral  incisors  in  the  lower 
jaw.  Then  about  the  twelfth  or  fourteenth  month  the  first  four 
molars  appear,  generally  those  of  the  lower  jaw  first ;  but  they 
do  not  follow  any  definite  order  in  their  appearance.  After  the 
lapse  of  another  three  or  four  months  the  four  canine  teeth  suc- 
ceed, and  between  the  twentieth  and  thirtieth  month  the  four 
posterior  molars  pierce  the  gum,  thus  completing  the  number  of 
twenty-four  teeth.  These  are  called  temporary  teeth.  The  jper- 
manent  teeth  are  thirtj^-two  in  number,  and  they  make  their 
appearance  as  the  former  are  shed. 

The  permanent  teeth  belong  to  that  important  period  of  child- 
hood— the  second  dentition.  These  teeth  begin  to  appear  between 
the  seventh  and  eighth  year,  and  at  this  time  there  are  forty- 
eight,  twenty  deciduous,  or  perfectly  developed  teeth,  and  twenty- 
eight  permanent  teeth  in  various  stages  of  development.  The 
evolution  of  the  first  true  molars  is,  according  to  Mr.  Saunders, 
an  evidence  that  the  child  has  attained  the  age  of  seven  years. 

The  following  table  is  of  assistance : 

Central  incisors  developed  at    8  years. 


Lateral  incisors          " 

9      " 

First  bicuspid             '' 

10     " 

Second  bicuspid         " 

11      " 

Canines                        " 

12    to  12^-  vears. 

Second  molarsf          " 

12^  to  14     " 

*  "  If  a  child  pass  over  the  ninth  month  without  teeth,  you  should  carefully  inquire 
for  the  cause.  It  may  be  that  an  acute  illness  has  retarded  dentition.  It  may  be  (but 
this  is  very  rare),  that  there  is  some  condition  of  the  gum  which  interferes  witli  the 
advance  of  the  teeth.  It  may  be  (and  this  is  infinitely  the  most  common  cause  of  late 
dentition)  that  the  child  Ls  rickety  ;  fail  not  then,  when  called  to  a  child  in  whom  tlie 
teeth  are  late  in  appearing,  to  look  if  it  be  rickety,  for,  if  you  do  fail  lo  look  for  rickets, 
you  will  most  likely  attribute  to  the  iriitation  of  teething  symptoms  wiiich  are  the 
consequence  of  the  rickety  diathesis — the  late  dentition  in  rickets  being  in  itself  merely 
a  .symptom  of  the  general  disorder.  TJie  rickety  deformities  may  be  very  trifling,  and 
yet  the  teeth  considerably  retarded  in  their  development." — Lectures  on  Rickets,  by  Sir 
William  Jenner,  Bart.,  M.D.     Medical  Times  and  Gazette,  vol.  i,  p.  334. 

f  Carpenter's  Physiology,  8th  edit.,  p.  1106. 


DENTITION.  69 

Symptoms. — The  symptoms  and  disorders  that  accompany  the 
first  dentition  vary  in  different  cases.  A  perfectly  healthy  child 
may  not  suffer  in  the  least  degree,  one  tooth  appearing  after 
another  without  causing  any  local  or  general  disturbance ;  but, 
in  many  instances  the  excitement  is  considerable  ;  the  mouth 
is  hot  and  swollen  ;  the  cheeks  are  flushed  ;  the  child  is  fretful 
and  sleepless ;  it  resents  the  slightest  interference  ;  the  appetite 
fails;  thirst  is  present,  and  often  sickness  and  diarrhoea  as  well. 
One  of  the  earliest  sj^mptoms  attending  dentition  is  an  increase  in 
the  activity  of  the  salivary  glands,  and  saliva  is  seen  to  be  con- 
stantly drivelling  from  the  mouth  ;  but  this  moisture  may  be 
present  for  some  weeks  before  the  teeth  appear.  In  some  cases  the 
constitutional  disturbance  is  even  greater  than  that  which  I  have 
described ;  the  mouth  is  hot  and  dry  ;  aphthous  ulceration  is  seen 
on  the  gums  and  inside  of  the  cheeks ;  the  tongue  is  thickly 
coated,  and  the  child  can  no  longer  suck.  Convulsions  and  spas- 
modic movements  are  very  common  in  teething  children.  Fre- 
quent contractions  of  the  muscles  of  the  eyes,  the  lids  of  which 
are  only  partially  closed,  and  the  eyes  turping  upwards  beneath 
the  upper  eyelids,  so  that  the  white  sclerotic  is  ouly  seen,  give  a 
terrified  expression,  and  is  alarming  to  the  parents.  Rolling  of 
the  head,  twitching  of  the  facial  muscles  and  of  the  limbs,  flexion 
of  the  toes  and  fingers,  and  a  peculiar  smile  are  often  observable 
at  such  a  time.  In  this  state  of  excitement  almost  any  sympa- 
thetic disorder  may  spring  up,  as  bronchitis,  convulsions,  menin- 
gitis, diarrhoea,  and  eczematous  and  erythematous  affections  of 
the  skin.  Some  of  these  affections  are  quickly  fatal,  and  others 
tedious  and  difiicult  of  cure.  In  rickety  children  dentition  is 
delayed.  They  are  feeble  in  constitution,  the  appetite  is  capri- 
cious, sleep  is  disturbed,  and  the  bowels  are  relaxed. 

During  dentition,  children  are  very  liable  to  diarrhoea,  the 
mucous  membrane  of  the  bowels  is  irritable  and  sensitive,  and  if 
the  food  given  is  not  easy  of  digestion,  or  if  the  weather  be  cold, 
it  is  easily  induced.  What  share  teething  exerts  in  causing  diar- 
rhoea it  is  impossible  to  say  ;  but  there  is  a  close  connection  exist- 
ing between  these  states  When  diarrhoea  is  present  we  do  not 
hastily  attempt  to  check  it  if  the  teeth  are  piercing  the  gums,  and 
the  mouth  is  uneasy  :  still,  if  the  drain  continues  or  is  excessive 
the  child  becomes  exhausted,  and  the  possibility  of  convulsions 
must  not  be  overlooked. 


70  DISEASES    OF    CHILDREN. 

Diarrhoea  may  be  in  some  measure  due  to  enfeebled  digestion 
caused  by  pain  and  restlessness,  and  general  disorder  of  the  system. 
Billard  attributed  it  to  an  increased  development  of  the  intestinal 
follicles  and  glands,  which  is  noticed  at  the  period,  of  dentition.* 
A  3'ear  of  delicate  health  may  elapse  before  a  tooth  is  seen,  and 
then  one  may  slowly  appear  without  causing  pain.  Convulsions 
in  a  case  under  my  care  preceded  the  appearance  of  each  tooth. 

Children  who  suffer  from  difficult  dentition  will  be  often  ob- 
served to  roll  the  head  from  side  to  side,  and  to  raise  the  hand  to 
it,  or  put  the  fingers  in  the  mouth.  Sickness  and  febrile  disturb- 
ance are  noticeable ;  the  child  becomes  languid  and  wastes,  the 
muscles  are  flabby  and  the  joints  relaxed,  the  motions  are  often- 
sive,  and  dark,  green,  or  slimy.  Slight  ulcerations  of  the  mouth 
are  common,  the  child  is  peevish  and  irritable,  it  experiences  pain 
on  taking  food,  and  does  not  obtain  sound  sleep. 

In  some  rickety  children  during  dentition,  sickness  and  vomit- 
ing are  the  chief  symptoms,  and  the  child  is  drowsy  and  inclined 
to  sleep  at  any  time  during  the  day.  If  the  head  is  hot,  and  the 
veins  distended  about  the  scalp,  the  pulse  quick,  and  the  temper- 
ature runs  up  to  101°  or  102°,  we  may  with  reason  dread  the  su- 
pervention of  convulsions  or  meningitis.  Convulsions  in  several 
children  of  the  same  family  are  often  to  be  met  with.  In  one  in- 
stance a  mother  had  lost  three  children  from  convulsions  during 
dentition ;  the  fourth  child  was  the  subject  of  laryngismus  strid- 
ulus, and  at  two  years  old  it  had  only  seven  teeth.  Laryngismus 
stridulus  frequently  attends  dentition  in  rickety  children,  the 
seizure  passing  off  as  the  teeth  appear,  and  the  general  condition 
improves.  Eruptions  on  the  face  and  scalp  have  been  usually  at- 
tributed to  dentition — the  "tooth-rash"  of  vulgar  talk. 

The  causes  of  difficult  and  delayed  dentition  are  an  acute  dis- 
ease, the  rickety  constitution,  struma,  marasmus,  and  tuberculo- 
sis. All  these  disorders  retard  the  development  of  the  teeth,  by 
lowering  the  general  health. 

In  some  cases  we  may  trace  the  failure  of  health  from  the  time 
of  vaccination  when  it  is  perfornied  at  the  third  or  fourth  month ; 
this  in  many  instances  seriously  interferes  with  the  development 
of  the  teeth,  and  disposes  to  reflex  nervous  irritation. 

The  mortality  under  the  age  of  two  years  has  been  variously 

*  On  the  Dangers  of  Dentition,  by  J.  Finlayson,'M.D.,  Obstetrical  Journal,  1873-74, 
p.  591. 


DENTITION.  71 

estimated  bj  different  writers,  some  ascribing  half  the  deaths, 
others  a  third,  and  others  again,  a  sixth,  as  due  to  difficult  denti- 
tion. 

The  treatment  of  dentition  will  depend  upon  the  general  symp- 
toms that  are  present,  and  the  constitution  of  the  patient.  The 
practitioner  must  exercise  his  own  judgment  as  to  the  treatment 
he  will  adopt,  and  not  blindly  attach  himself  to  any  routine  plan. 
The  strong  and  vigorous  child  who  is  feverish  and  thirsty,  with  a 
hot  and  tender  gum,  a  full  pulse,  and  constipated  bowels,  will  de- 
mand quite  a  different  mode  of  management  from  a  puny  and 
rickety  child  whose  teeth  are  delayed.  In  strong  children  a  grain 
of  calomel  with  two  or  three  grains  of  rhubarb  will  be  required 
to  clear  the  bowels.  A  saline  mixture,  as  the  citrate  of  potash, 
should  be  given  to  abate  the  pyrexia,  and  if  the  child  is  excited 
and  sleepless,  a  few  drops  of  tincture  of  henbane  may  be  added, 
or  a  draught  at  bedtime  containing  hydrate  of  chloral  and  bro- 
mide of  potassium,  should  be  given.  The  child's  head  should  be 
kept  cool,  and  whatever  determines  to  cerebral  congestion  should 
if  possible  be  prevented.  "Affusions  of  the  head  with  cold  water, 
performed  every  hour  or  two,  are,  it  is  true,  a  not  very  tender,  and 
by  parents  not  much  admired,  remedy  ;  it  is,  however,  very  useful 
against  all  convulsions  in  children,  and  therefore  against  those  oc- 
curring during  dentition."* 

In  the  rickety,  a  mild  aperient  is  occasionally  required,  such  as 
bicarbonate  of  soda  and  rhubarb,  to  regulate  the  bowels,  and  to 
correct  the  secretions.  A  teaspoonful  of  castor  oil  may  be  advis- 
able now  and  then,  and  if  the  bowels  are  over  active,  a  grain  of 
Dover's  powder  at  bedtime  is  often  of  great  service.  If  there  is- 
vomiting  and  flatulence  some  carminative  will  be  necessary.  A 
mixture  containing  hydrocyanic  acid  with  solution  of  magnesia 
and  sal  volatile  often  answers  exceedingly  well.f  In  cases  where- 
there  is  much  restlessness  and  disturbance  of  the  nervous  system, 

*  Vogel,  Diseases  of  Children,  1874,  p.  106. 

f  Formula  2 : 

R.  Acid.  Hydrocy.  Dil., ^ss.. 

Spt.  Amra.  Arom.,         ........     Ttjjij 

Syrupi, njjxx 

Liquor.  Magn.  Carb., 3j. — M".. 

To  be  taken  every  four  hours. 


72  DISEASES   OF    CHILDREN. 

bromide  and  iodide  of  potassium  with  sal  volatile  will  often  abate 
sickness,  and  relieve  head-sjmiptoms  if  present.* 

The  gum-lancet  is  occasionally  required.  If  the  tooth  is  nearly 
through,  but  still  hidden,  and  the  gum  is  red  and  tightly  stretched 
over  the  tooth,  then  a  proper  incision  will  give  much  ease,  and  the 
slight  bleeding  will  relieve  the  capillary  vessels.  It  is  both  mis- 
chievous and  cruel  to  have  recourse  to  the  practice  if  dentition  is 
going  on  naturally.  This  practice  of  lancing  the  gums  is  a  very 
old  one.  It  appears  inconsistent  with  the  state  of  medicine  in  the 
present  day  to  suppose  that  puncturing  the  gums  would  be  so 
frequently  resorted  to  if  it  had  no  advantages.  "  May  not  some 
diseases  be  rendered  milder,  and  their  favorable  termination  more 
certain  or  probable  by  measures  calculated  to  relieve  the  turges- 
cence  of  the  gums  ?  If  so,  those  who  totally  disregard  the  state 
of  the  gums,  are  not  less  in  error  than  those  who  use  the  gum- 
lancet  when  it  is  not  required. "f  The  cases  where  incision  is  re- 
quired are  probably  few,  but  there  are  undoubtedly  some  which 
do  benefit  by  the  operation,  and  where  convulsions  have  been  pre- 
vented by  having  recourse  to  it.  When  the  gum  has  yielded  to 
the  advancing  tooth  a  child  often  experiences  instant  relief  and 
comfort.  So  far  from  causing  the  infant  pain,  I  have  repeatedly 
lanced  the  gum  without  the  child  evincing  the  slightest  indication 
of  feeling  pain  from  it,  but  of  obtaining  speedy  relief.  I  have 
never  seen  haemorrhage  or  ulceration  of  the  gums  follow,  and  in 
properly  selected  cases  it  certainly  has  its  advantages. 

Finally,  care  in  diet  is  of  the  greatest  importance  whilst  a  child 
is  teething.  Improper  food  will  easily  bring  on  acute  indigestion 
and  febrile  exciten^ent,  demanding  the  use  of  salines  and  aperients 
till  the  system  is  again  tranquil. 


*  Formula  3 : 

R.  Potass.  Bromid., gr.  ij 

Potass.  lodidi, gr.  i 

Spt.  Amm.  Arom., "JJij 

Synipi, ")Jxx 

Aquam  ad    .........        .     SJ- — ^i- 

To  be  taken  every  four  hours.     For  children  a  year  old. 

•f  Diseases  of  Children,  by  J.  Lewis  Smith,  M-D.,  18G9,  p.  307. 


MARASMUS   OR   ATROPHY.  73 

CHAPTER    VI. 

MARASMUS   OR    ATROPHY. 

Nature  and  definition  of— Deficient  food  the  most  common  cause — Mortality  amonr/  infants 
— In  treatment  the  primary  object  is  to  remove  the  cause — Care  in  feeding — Cod-liver 
oil—Raw  meat  juice — Digestive  ferments — Liquor  Pepticus  and  Liquor  Pancreaticvs 
— Saline  essences  of  pepsin  and  pancreatin  —  Acid  glycerin  of  pepsin — Artificial 
digestion. 

Atrophy  consists  in  the  decrease  of  size  of  a  tissue,  or  of  the 
whole  body,  with  consequent  impairment  of  function.  It  is  the 
opposite  state  to  that  known  as  hypertrophy.  When  adipose  tissue 
atrophies,  the  fat-cells  diminish  in  size,  owing  to  the  gradual  loss 
of  their  contents,  and  emaciation  results.  The  elementary  con- 
stituents of  any  other  tissue,  or  organ,  or  set  of  organs  may  become 
similarly  affected,  and  so  produce  diminution  in  size,  and  a  pro- 
portionate impairment  of  function.  It  is  not  the  same  process  as 
degeneration,  although  degeneration  is  always  sooner  or  later 
accompanied  by  atrophy.  Degeneration  consists  in  the  deteriora- 
tion of  the  qualify  of  a  tissue,  and  does  not  (at  all  events  at  first) 
necessarily  imply  diminution  in  its  size.  On  the  contrary,  the  size 
may  be  temporarily  increased,  as,  for  instance,  in  fatty  degeneration 
of  the  liver. 

Atrophy  is  a  common  disease  among  infants  and  young  children, 
as  the  out-patient  practice  of  any  London  hospital  amply  testifies. 
It  has  its  origin  in  defective  nutrition,  and  is  rather  to  be  regarded 
as  a  state  of  extreme  debility.and  lowered  vitality  than  as  a  specific 
and  independent  affection. 

"  Experience  has  taught  us  that  patients  often  die  without 
offering,  in  the  post-mortem  examination,  the  slightest  modifica- 
tion in  the  anatomical  condition  of  their  organs.  In  the  course  of 
our  physiological  experiments,  we  often  see  dogs  arrived  at  the 
very  last  stage  of  emaciation,  although  the  appetite  continues 
unimpaired  till  the  last  moment.  They  sink  from  sheer  exhaustion, 
while  the  lacteal s  are  gorged  with  chyle;  and,  when  opened,  their 
bodies  offer  no  trace  whatever  of  pathological  alteration."* 

Causes. — Whatever  interferes  with  the  nutrition  of  an  organ  is 
followed  by  its  atrophy.     If  the  food  given  to  an  infant  be  un- 

*  LectiD'e  on  Experimental  Pathology,  by  Claude  M.  I'ernard,  Medical  Times  and 
Gazette,  1860,  vol.  i,  p.  209. 


74  DISEASES    OF   CHILDREN. 

wholesome-  or  deficient,  the  digestive  organs  are  sooner  or  later 
deranged,  and  the  processes  of  assimilation  are  disturbed.  The 
nutritive  changes  in  growing  tissues  are  far  more  active  than  in 
the  mature;  consequently  any  interference  with  the  nutrition  of 
an  infant  is  followed  by  far  more  rapid  and  serious  consequences 
than  in  the  case  of  an  adult. 

It  has  been  pointed  out  by  Dr.  Murchison  that  emaciation  may 
arise  from  functional  derangement  of  the  liver,  as  when  the  bile  is 
impeded  in  its  passage  into  the  bowel,  and  the  assimilation  of  fatty 
and  albuminous  matters  is  interfered  with,  or  from  deraiigement 
of  the  glycogenetic  function  of  the  liver.*  It  may  also  arise  from 
stricture  or  obliteration  of  the  thoracic  duct;  by  which  means  the 
chyle  elaborated  by  the  mesenteric  glands  fails  to  reach  the  general 
circulation.  Atrophy  is  also  caused  by  whatever  occasions  any 
great  waste  of  nutritive  material.  Thus,  prolonged  hfemorrhages, 
long-continued  suppuration,  excessive  vomiting  and  diarrhoea,  by 
depriving  the  body  of  large  quantities  of  nutritive  matter,  lead  to 
general  atrophic  changes. 

As  to  some  other  causes  of  atrophy,  the  most  frequent  are  any 
circumstances  that  bring  about  defective  nutrition  in  infants  and 
very  young  children.  A  child  may  have  been  born  healthy,  but 
the  mother  is  suddenly  unable  to  suckle  it,  and  from  that  moment 
it  ceases  to  thrive.  'No  artificial  food  can  efliectuallj^  take  the  place 
of  the  mother's  milk,  the  child  wastes  and  becomes  emaciated, 
diarrhoea  and  vomiting  ensue,  and  it  dies  exhausted.  In  another 
class  of  cases  the  child  is  incessantly  sick,  and  life  is  frequently 
arrested  by  an  attack  of  convulsions.  Hundreds  of  infants  die 
annually  in  London  and  other  large  cities  because  the  food  given 
to  them  is  either  unwholesome,  indigestible,  or  insufiicient,  their 
digestive  organs  are  too  feeble  to  assimilate  it,  or  the  mother  is 
working  hard,  and  in  delicate  health  at  the  same  time,  and  so  has 
not  sufiieient  breast-milk  to  nourish  her  infant.  We  continually 
see  pale  and  feeljle  women  bringing  up  their  children  by  the  breast 
when  a  year  old,  and  they  tell  us  with  some  surprise  that  since 
their  milk  diminished  the  children  have  not  thriven.  The  blood, 
in  these  cases,  gets  into  a  thoroughly  impoverished  state,  and  the 
mammarj' glands  can  no  longer  secrete  milk  sufiieient  in  quantity, 
or  good  in  quality. 

*  Croonian  Lectures  on  Functional  Derangements  of  the  Liver,  The  Lancet,  1874, 
vol.  i,  p.  4G7. 


MARASMUS  OR  ATROPHY.  75 

It  has  been  pointed  ont  that  food  ricli  in  starchy  products  is  a 
common  cause  of  atrophy  in  young  children  when  given  to  them 
before  the  salivary  and  pancreatic  glands  have  reached  their  full 
development.  Before  the  seventh  or  eighth  month  the  starch  is 
not  converted  into  glucose  or  sugar,  and  hence  one  cause  of  indi- 
gestion and  defective  nutrition.* 

The  mortality  among  infants  brought  up  by  hand  is  enormous.f 
The  deaths  during  the  first  two  months  are  four  times  the  number 
during  the  third  month.]:  Where  infants  are  imperfectly  fed, 
nutrition  takes  a  wrong  direction,  and  if  they  do  not  flag  or  die 
earl}-,  then  some  morbid  deposit  in  the  shape  of  tubercle  may  be 
infiltrated  into  the  difterent  organs,  or  some  inflammatory  afl:ec- 
tion  set  up. 

Sometimes  young  children,  without  any  ascertained  cause,  sud- 
denly become  fretful  and  irritable,  and  lose  flesh  and  strength  ; 
the  face  grows  pale,  and  the  body-heat  diminishes ;  in  these  cases 
they  sleep  badly,  there  is  uneasiness  in  the  bowels ;  the  motions 
are  dark  and  offensive,  and  death  gradually  follows. 

"  In  chronic  atrophy  the  last  traces  of  adipose  tissue  disappear 
from  the  face  ;  the  integument  everywhere  becomes  loose  and  cor- 
rugated, and,  in  addition,  various  contractions  of  the  muscles 
take  place,  as  a  result  of  cerebral  irritation,  especially  that  of  the 
frontal,  next  of  the  corrugator  supercilii,  and  the  levator  al?e  nasi 
et  labii  superioris  muscles,  by  which  the  face  acquires  a  senile  ap- 
pearance, and,  on  account  of  which,  the  French  Psediatricars,  in  a 
very  ungallant  manner,  call  it  a  Yoltairean  face."§ 

*  See  Chapter  II. 

t  "In  England,  out  of  100  children  born  ;  while  for  the  whole  period  of  one  year 
15.2  per  cent,  children  will  die  tlie  first  month,  1.7  the  next,  and  so  on.  In  France, 
out  of  a  million  births,  29,121  die  in  the  first  week,  22,128  in  the  second,  and  22,236 
in  the  sixteen  days  following." — On  Infant  Feeding,  by  C.  H.  F.  Routh,  M.D.,  ISTfi,  p.  64. 

X  "According  to  the  English  Life-Table,  of  1,000,000  cliildren  born,  149,493  die 
before  they  reach  the  age  of  one  year ;  and  of  these  149,493  deaths,  46,503,  or  nearly  a 
third,  die  during  the  first  month  of  life.  The  annual  rate  of  mortality  per  1000  among 
infants,  according  to  this  Englisli  Life-Table,  is  equal  to  571.3  in  the  first  month  of  life ; 
declining,  however,  to  91.6  per  1000  in  the  eleventh  month.  The  annual  rate  among 
infants  aged  one  month  and  under  one  year  does  not  exceed  114.6  per  1000;  whereas 
among  infants  from  birth  to  one  year  of  age  it  is  equal  to  165.6.  It  is  evident  that  in 
dealing  with  tlie  mortality  among  infants  during  the  first  year  of  life  it  is  necessary  to 
take  account  of  the  age  in  months  at  insurance,  for  the  rate  of  mortality  among  infants 
aged  six  months  is  but  one-fiftli  of  the  rate  whicli  prevails  during  the  first  month  of 
life." — Infant  Insurance  and  Mortality,  Brit.  Med.  Journal,  vol.  i,  1S75,  p.  785. 

2  Vogel,  Diseases  of  Children,  1874,  p.  15. 


76  DISEASES    OF   CHILDREN. 

In  the  treatment  of  3farasmus  and  Atrophy  we  must  seek  to 
remove  whatever  influences  appear  to  have  induced  the  disorder. 
If  the  mother  has  not  milk  enough  to  support  her  infant,  a  wet- 
nurse  shoukl  be  procured,  or  it  must  be  brought  up  by  hand,  and 
every  care  ought  to  be  bestowed  on  feeding,  according  to  the  age 
and  digestive  capabilities  of  the  child.  Into  this  question  I  have 
already  entered.*  Cod-liver  oil  may  be  given  to  young  infants 
after  food  in  these  cases,  with  the  greatest  advantage ;  it  will  have 
the  eft'ect  of  improving  the  appetite,  promoting  sleep,  correcting 
the  secretions,  and  increasing  weight.  When  it  does  good,  sick- 
ness is  not  induced  ;  indeed,  I  have  seen  many  infants  cease  to  be 
sick  on  taking  the  oil.  Half  a  teaspoonful  of  steel  wine  may  be 
added  to  the  oil  in  suitable  cases.  If  cod-liver  oil  cannot  be  borne 
an  equal  quantity  of  glycerin  may  be  given  with  good  results. 
It  is  usually  taken  with  relish.  Inunction  of  cod-liver  oil  is  also 
of  service.  Haw  in  eat  juice  in  some  cases  of  atrophy  and  wasting 
proves  highly  nutritious  and  digestible.  The  directions  for  pre- 
paring it  are  given  in  another  place.f 

Cases  will  sometimes  occur  in  which  the  digestive  functions  are 
completely  in  abeyance.  All  foods  are  rejected  by  the  stomach 
or  passed  undigested  by  the  bowel.  In  such  cases  as  these,  as 
indeed,  in  all  where  the  alimentary  tract  is  in  a  high  degree 
of  irritation,  the  principle  of  physiological  rest  will  be  found 
to  be  of  great  value.  We  must  give  the  digestive  organs  as 
little  to  do  as  possible;  as  they  cannot  perform  their  functions 
effectually,  we  must  relieve  them  of  this,  by  introducing  arti- 
ficially digested  food,  and  thus  reduce  their  work  to  that  of 
mere  absorption.  This  can  be  eftected  by  "peptonizing  "  the  food 
before  it  is  given.  There  are  several  valuable  preparations  of  the 
digestive  ferments  in  the  market,  while  many  are  practically  inert. 
Amongst  the  most  effective  may  be  mentioned  Benger's  prepara- 
tions, the  "  Liquor  Pepticus  "  and  "  Liquor  Pancreaticus  ;"  Savory 
and  Moore's  two  saline  essences  of  Pepsin  and  Pancreatin, 
Bullock's  Acid  Glj^cerin  of  Pepsin  (which,  on  account  of  its 
sweetness,  is  readily  taken  by  children),  and  others.  The  strength 
of  these  preparations  is  very  similar.  Dr.  W.  Roberts  has  called 
attention  to  this  subject  in  his  Lunileian  Lectures  on  the  Digestive 
Ferments.     He  says:  "Any  extract  of  pancreas  may  be  used  for 

*  See  Chapter  II.  f  See  Chap.  XV,  On  Diarrlioea. 


MARASMUS   OR   ATROPHY.  77 

the  preparation  of  artificially  digested  food,  but  the  most  suitable 
are  those  prepared  with  dilute  spirit  or  chloroform-water.  The 
extract  sent  out  by  Mr.  Beuger,  uuder  the  name  of  '  Liquor  Pan- 
creaticus,'  is  an  almost  faultless  pharmaceutical  preparation.  It  is 
made  by  extracting  perfectly  fresh  and  finely  chopped  pancreas, 
with  four  times  its  weight  of  dilute  spirit.  By  some  ingenious 
devices,  Mr.  Benger  has  succeeded  in  overcoming  the  mechanical 
difficulties  of  the  manufacture,  and  has  produced  an  extract  w^hich 
possesses  the  diastatic  and  proteolytic  properties  of  the  pancreas  in 
a  highly  concentrated  degree.  It  is  a  nearly  colorless  solution, 
with  ver\'  little  taste  or  smell  beyond  that  of  the  spirit  used  to 
preserve  it."*  The  following  are  Dr.  Roberts's  methods  of  arti- 
ficially digesting  milk  and  milk-gruel: 

'"■a.  Peptoxized  Milk. — Fresh  milk  is  diluted  with  water  in  the 
proportion  of  three  parts  of  milk  to  one  part  of  water.  A  pint  of 
this  mixture  is  heated  to  boiling,  and  then  poured  into  a  covered 
jug.  When  it  has  cooled  down  to  about  140°  Fahr.,  three  tea- 
spoonfuls  (foiij)  of  the  Liquor  Pancreaticus,  and  twenty  grains 
(about  half  a  small  teaspoouful)  of  bicarbonate  of  soda  (in  solution) 
are  mixed  therewith.  The  jug  is  then  placed  under  a  'cosey '  in  a 
warm  situation  for  one  hour.  At  the  end  of  this  time  the  product 
is  again  boiled  for  a  couple  of  minutes.  It  can  then  be  used  like 
ordinary  milk. 

"  b.  Peptonized  Milk-Gruel. — Half  a  pint  of  well-boiled  gruel 
is  added,  while  still  boiling  hot,  to  half  a  pint  of  cold  milk  in  a 
covered  jug.  The  mixture  will  have  a  temperature  of  about  125" 
Fahr.  The  Liquor  Pancreaticus  and  the  bicarbonate  of  soda  are 
then  added  in  the  same  proportion  as  in  the  preceding  process  {a). 
The  jug  is  placed  under  a  'cosey'  and  kept  warm  for  an  hour  and 
a  half.  The  contents  are  then  boiled  for  a  couple  of  minutes,  and 
the  product  is  ready  for  use.  By  this  second  method  the  use  of 
the  thermometer  is  dispensed  with." 

In  cases  of  great  debility  and  exhaustion  it  may  become  neces- 
sary to  feed  the  child  per  rectum. 

The  following  is  Dr.  Roberts's  plan  of  preparing  nutritive 
enemata:  "A  nutritive  enema  should  be  prepared  in  the  usual 
way — of  milk,  or  of  milk  with  beef  tea  or  eggs,  or  of  milk-gruel. 

*  Lumleian  Lectures,  On  the  Digestive  Ferments,  by  W.  Eoberts,  M.D.,  F.E.S., 
The  Lancet,  April,  1880,  to  which  the  reader  is  recommended  to  refer  for  further  par- 
ticulars. 


78  DISEASES   OF   CHILDREN. 

To  half  a  pint  of  the  warm  enema  a  tablespoonful  of  the  Liquor 
Pancreaticus,  and  thirty  grains  of  bicarbonate  of  soda  should  be 
added.     The  enema  can  then  be  administered  at  once." 

Two  ounces  is  quite  sufficient  at  one  time,  for  if  more  be  used 
it  ma}^  not  be  retained. 


CHAPTER   VII. 

FEVERS   OF    CHILDHOOD. 


Definition  of  fever — Its  causes  and  symptoms — Action  of  the  fever-poison  on  the  blood  and 
nervous  system — Termination  by  critical  change  or  crisis — General  management  of  fevers, 
prophylactic  and  curative — Simple  febricida — Febris  ephemera — Febris  continua  sim- 
plex— Its  definition,  causes,  symptoms,  and  treatment. 

The  term  fever  is  employed  to  signify  an  accelerated  state  of 
the  circulation,  with  thirst,  loss  of  appetite,  elevation  of  temper- 
ature, prostration  of  the  mental  and  bodily  powers,  and  derange- 
ment in  the  secreting  functions.  These  changes  are  the  conse- 
quences of  external  causes,  which  the  system  is  unable  to  resist. 
The  causes  may  be  sudden  or  slow,  powerful  or  mild  ;  they  may 
temporarily  impede  its  actions,  and  eventuate  in  a  speedy  restora- 
tion to  health  ;  or  they  may  induce  a  combination  of  phenomena 
which  destroy  the  life  of  the  patient. 

All  diseases  which  exhibit  febrile  symptoms  at  their  commence- 
ment must  have  a  close  resemblance  to  one  another,  and  do  not 
then  admit  of  a  diagnosis,  which  is  easy  at  a  later  period,  when 
the  development  of  particular  symptoms  enables  us  to  fix  the 
exact  nature  of  the  affection,  and  in  many  instances  to  trace  its 
origin.  Different  individuals  are  variously  afiected  according  to 
peculiar  circumstances,  and  the  state  of  the  general  health  at  the 
time  of  attack.  Thus  exposure  to  cold  and  moisture  in  one  per- 
son produces  only  a  feeling  of  malaise  and  general  constitutional 
disturbance ;  it  docs  not  fix  upon  any  particular  organ,  and  ter- 
minates without  complication.  In  another  person,  as  the  general 
disease  advances,  there  is  a  determination  of  the  complaint  to 
some  organ  ;  or  in  a  third  person  tlie  local  disease  may  proceed  as 
rapidly  or  even  more  so  than  the  general  disorder  ;  and  this  is 
exemplified  in  some  cases  of  pneumonia  occurring  in  young  and 


FEVEES   OF   CHILDHOOD.  79 

vigorous  subjects.  Then  there  is  a  class  of  cases  in  which  the 
local  disorder  precedes  the  constitutional,  and  the  inflammatory 
sj'mptoms  increase  and  become  more  developed,  whilst  the  symp- 
tomatic fever  and  general  derangement  follow  later. 

Increased  heat  and  accelerated  circulation 'constitute  fever,  and 
without  them  the  patient  cannot  be  said  to  labor  under  it.  In 
the  early  stages  they  may  be  absent,  as  during  the  period  of  de- 
pression and  lassitude,  when  the  vital  energies  are  prostrate,  and 
before  the  system  has  shown  any  reaction.  But  quickly  come  re- 
markable changes  and  manifestations,  as  uneasiness,  restlessness, 
shivering,  coldness  along  the  spine,  involuntary  tremors,  rigors  or 
convulsions,  and  exacerbations.  And  to  these  succeed  lesions  of 
the  organic  functions,  in  disturbed  respiration,  circulation,  diges- 
tion, and  nutrition  ;  the  attitude  is  altered,  the  expression  changed, 
and  the  intellectual  powers  enfeebled  or  destroyed.  The  symptoms 
are  owing  to  changes  in  the  quality  and  constituents  of  the  blood, 
which  becomes  altered  in  color  and  consistence,  the  serum  in- 
creased, and  the  crassamentum  thickened  or  loosened.  Then  fol- 
low changes  in  the  quality  and  amount  of  the  secretions ;  they 
become  putrid  and  offensive  to  the  tissues  in  which  they  are  in 
contact,  and  lead  to  local  inflammations  and  changes  of  structure. 
The  fever-poison  enters  the  blood  and  paralyzes  the  nervous  sys- 
tem— it  afiects  all  the  solids  and  fluids  of  the  body,  and  tends  to 
the  disturbance  of  its  several  functions.  It  is  well  that  we  should 
bear  in  mind  the  liability  of  the  mildest  form  of  fever  to  change 
its  characters  and  become  developed  into  a  dangerous  type  at  some 
period  of  its  progress  ;  and  hence  it  is  that  very  mild  cases  of 
typhoid  (remittent)  pass  oif  in  a  few  days,  whilst  in  others  they 
become  severe,  protracted,  and  even  fatal.  From  constitutional 
infirmity  or  improper  diet,  alarming  symptoms  may  arise  at  any 
period  of  the  fever,  or  if  the  blood  is  surcharged  with  the  con- 
taminating elements  of  tissue  metamorphosis,  which  the  excretory 
channels  cannot  eliminate,  coma  or  delirium  may  set  in  unexpect- 
edly and  destroy  the  patient's  life.  Thus  it  becomes  a  trite  maxim, 
which  observation  daily  indorses,  that  "  where  there  is  fever  there 
is  danger." 

All  fevers  have  a  tendency  to  terminate  by  critical  change  or 
crisis,  as  it  has  been  termed,  if  the  vital  powers  are  not  too  much 
exhausted.     This  is  seen  in  ague  and  some  idiopathic  fevers,  in 


80  DISEASES    OF    CHILDREX. 

which  a  free  sweating,  or  evacuation  from  the  bowels,  is  followed 
by  favorable  symptoms. 

In  the  management  of  fevers  in  general  there  are  prophylactic 
and  curative  measures  to  be  borne  in  mind.  If  the  causes  which 
produced  the  fever  can  be  ascertained  they  should  be  removed,  and 
the  patient  placed  under  the  most  favorable  hygienic  conditions. 
Such  measures  should  be  resorted  to  as  support  the  constitutional 
powers  and  encourage  the  due  performance  of  the  different  func- 
tions of  the  body.  Excess  of  food,  by  inducing  vascular  plethora 
and  general  excitement,  will  predispose  to  fever,  whilst  moderate 
exertion  of  the  mind  and  body,  and  the  inculcation  of  habits  which 
neither  overexcite  nor  depress,  will  enable  the  child  of  delicate 
physical  organization  to  resist  the  infectious  effluvia  or  other  epi- 
demic influences  which  strike  down  the  robust  and  strong.  In 
districts  where  the  soil  is  low  and  heavy,  and  there  are  many  trees, 
children  should  not  be  exposed  to  the  night  or  morning  air  on  an 
empty  stomach,  and  if  it  can  be  managed  their  apartments  should 
be  at  the  top  of  the  house.  In  the  autumn  season  of  the  year  an 
occasional  dose  of  quinine  and  a  mild  aperient  will  be  advisable  in 
unhealthy  localities.  In  short,  a  due  regulation  of  the  digestive 
and  secreting  functions  should  be  observed,  and  all  causes  that 
morally  or  physically  depress  the  system  should  be  carefully 
avoided.  When  the  impression  of  fever  has  been  made,  its  full 
development  may  sometimes  be  prevented  by  a  careful  diet,  rest 
in  bed,  laxative  medicines,  and  cooling  drinks  ;  by  the  employment 
of  a  warm  bath,  or  determining  the  blood  to  the  external  surface. 
Although  these  measures  ma}'  not  arrest  the  fever,  they  will  con- 
trol the  premonitory  stage,  and  render  the  subsequent  disease 
milder  and  shorter  in  its  duration.  We  shall  treat  of  the  serious 
complications  that  arise  in  the  course  of  the  specific  fevers  under 
their  respective  heads. 

Simple  febricula^  or  feverishness,  is  the  term  I  would  employ  to 
express  a  slight  degree  of  febrile  action.  It  may  be  classed  as  a 
mild  grade  of  inflammatory  or  continued  fever  terminating  in 
twenty-four  hours,  or  lasting  over  a  few  days.  The  aft'ection  is 
not  jjeculiar  to  children  and  may  occur  to  adults.  The  mildest 
variety  is  generally  caused  b}'  fatigue  and  exposure  to  the  sun  in 
hot  weather,  or  by  prolonged  mental  excitement,  or  by  continuous 
study  in  close  rooms.  I  have  met  with  several  instances  of  this 
kind  and  almost  invariably  in  the  summer  season  of  the  year. 


FEVERS   OF   CHILDHOOD.  81 

when  the  weather  has  suddenly  changed,  and  Ijecome  hot  and  re- 
laxing. In  May,  1877,  three  children,  aged  respectively  five, 
seven,  and  eight  years,  were  brought  to  me  in  the  Out-patient  De- 
partment of  the  Samaritan  Hospital  on  the  same  day,  with  tem- 
peratures vaFying  from  101.6°  to  lOi.i'"  (rectum).  May  14th. — 
The  youngest  child  had  the  highest  temperature.  She  had  been 
ailing  for  a  week,  refused  food,  and  was  extremely  thirsty  and 
fretful ;  there  was  a  shrill  croupy  cough,  and  the  hands  and  body 
were  very  hot ;  pulse  140,  respirations  50  per  minute  ;  the  tongue 
was  whitish  and  moist,  and  one  or  both  cheeks  flushed  both  morn- 
ing and  evening  ;  there  was  no  diarrhoea,  and  the  urine  was  clear. 
I  thought  the  case  very  like  typhoid  fever,  or  acute  tuberculosis; 
rather  the  latter  affection.  I  ordered  half  a  grain  of  quinine  in 
a  powder  with  sugar  night  and  morning,  and  a  mixture  of  citrate 
of  potash  and  bromide  of  potassium  three  times  a  day.  On  the 
17th  she  was  no  better,  refusing  beef  tea  and  scarcely  taking  any 
milk;  there  was  constant  cough  and  the  bowels  were  inclined  to 
be  loose.  The  temperature  in  the  rectum  was  104.2°,  pulse  140, 
respirations  50.  On  admission  as  an  in-patient  two  days  later 
(19th),  although  no  change  had  been  made  in  the  treatment,  the 
temperature  at  8  p.m.  was  98.2°,  and  it  never  exceeded  98.6^  dur- 
ing the  month  she  remained  in  the  hospital.  On  a  careful  exami- 
nation of  the  thorax  some  slight  mucous  rales  were  detected  when 
the  child  coughed  or  cried,  but  there  was  no  dulness  anywhere. 
The  urine  was  cloudy  and  contained  phosphates  in  abundance.  A 
mixture  of  phosphoric  acid  and  quinine  was  prescribed,  and  a  w^eek 
later  the  child  was  running  aboat  the  ward,  eating  an  ordinary 
diet,  and  left  the  institution  on  the  16th  of  June  quite  Avell.  In 
the  absence  of  local  or  specific  disease,  we  must  classify  these  cases 
as  "simple  febricula"  or  "pyrexia." 

This  fever  is  also  the  consequence  of  local  irritation  and  tem- 
porary obstruction  to  the  digestive  functions.  If  the  source  of 
irritation  resides  in  the  stomach  from  an  undigested  meal,  au> 
emetic  gets  rid  of  the  offending  mass,  and  subdues  the  fever  at 
once.  If  digestion  has  advanced  to  the  stage  of  imperfect  chyli>- 
fication,  the  separation  of  nutritive  elements  does  not  properly 
take  place,  and  absorption  of  well-selected  elements  does  not 
ensue ;  whilst  there  is  retained  in  the  intestinal  canal  matters^ 
which  also  become  sources  of  irritation  till  an  active  aperient, 
washes  them  out  of  the  system.     Hence  the  rapidity  with  whichj 

6 


82  DISEASES   OF   CHILDREN. 

this  simple  variety  of  fever  departs,  leaving  behind  it  no  ill  effects. 
Worms  in  the  intestinal  canal,  excessive  secretion  of  bile,  indul- 
gence in  stimulants  may  induce  it.  However  simple  the  fever 
may  be,  it  is  marked  by  a  coexistence  of  symptoms,  and  is  not 
characterized  by  any  single  one.  It  depends  on  a  variety  of 
exciting  causes,  and  is  not  specific,  nor  does  it  present  anj^thing  of 
a  definite  character  like  those  cases  of  fever  arising  from  conta- 
gion, in  which  there  is  a  change  in  the  healthy  proportion  of  the 
constituents  of  the  blood.  During  the  period  of  the  first  denti- 
tion the  infant  is  liable  to  pyrexia,  which  passes  off  with  the  ap- 
pearance of  the  tooth  through  the  distended  gum ;  or  it  may 
have  convulsions,  which  may  depart  quickly  or  return  from  time 
to  time,  and  even  end  fatally  if  the  process  is  slow,  and  the  con- 
stitution is  intolerant  of  the  irritation  through  excitability  of  the 
nervous  system.  When  the  fever  arises  from  the  various  causes 
which  excite  gastric  or  intestinal  disorder,  it  may  be  called  symp- 
tomatic fever,  for  there  is  neither  shivering,  brown  tongue,  nor 
active  cerebral  disturbance,  which  belong  to  the  exanthematous 
fevers.  Still  caution  is  necessary,  as  severe  fevers  often  set  in 
with  very  mild  symptoms.  It  is  doubtful  whether  such  cases  ever 
lead  to  a  fatal  termination.  The  temperature  from  slight  sources 
of  irritation  in  these  cases  may  rise  to  105°  Fahr.  in  the  evening 
(as  high  as  is  common  in  typhoid  fever)  and  fall  to  the  normal 
point  next  morning.  In  fact,  a  high  temperature  in  children  is 
often  a  delusive  indication  when  not  viewed  in  connection  with 
other  symptoms.* 

In  this  symptomatic  fever  (for  I  still  cling  to  the  term  in  the 
short  variety  of  the  afl'ection)  the  lassitude  and  general  weakness 
are  slight,  because  the  nervous  centres  are  not  severely  depressed, 
whereas  in  the  specific  fevers  they  are  sometimes  involved  to  a  great 
extent,  and  the  cerebral  functions  are  destroj^ed  or  seriously  in- 

*  "  Cases  of  ephemeral  fever,  without  any  very  serious  foundation  (bedeutungnvolle 
Begrundung),  are  particularly  cliaracteristic  of  the  period  of  childhood.  Therefore,  in 
children's  diseases,  even  when   we  find  a  very  high  temperature,  we  must  be  very 

■  careful  in  drawing  conclusions  from  the  first  (or  a  single)  observation.  At  tiiis  age 
also  more  or  less  high  temperatures  may  occur  at  stages  (Punkten)  in  the  course  of  a 

•  disease,  in  which  we  generally  find  very  moderate  or  normal  temperatures  in  the  adult. 
And  even  in  convalescence,  especially  after  muscular  exertions,  very  considerable  ele- 

^vations  of  temperature  are  sometimes  met  with  in  children." — Wunderlich,  On  Medical 

'.Thermometry,  New  Syd.  Soc,  1871,  p.  208. 


TYPHOID   FEYEE.  83 

volved,  as  when  effusion  takes  place,  or  the  concentration  of  the 
special  poison  partially  or  completely  paralyzes  them. 

Treatment. — This  consists  in  the  tirst  instance  in  giving  cooling 
drinks,  and,  in  the  shape  of  nutriment,  nothing  beyond  milk  and 
seltzer  water.  A  few^  alterative  doses  of  gray  powder  and  rhu- 
barb, or  a  brisk  purge,  wnll  bring  down  the  temperature  and  soon 
set  matters  right.  Sometimes  an  emetic  acts  like  a  charm.  The 
cause  has  only  to  be  removed,  and,  if  not  long  in  operation,  the 
child  is  quickly  restored  to  its  usual  health.  There  is  no  serious 
congestion  or  irritation  of  any  particular  organ,  and  consequent  I}'' 
the  depurating  functions  are  only  temporarily  impaired.  As  soon 
as  the  fever  begins  to  decline  (or  before,  if  there  is  much  moisture 
on  the  skin)  quinine  given  three  times  a  day  will  be  found  of  great 
service.  In  those  cases  where  there  is  a  febrile  paroxysm  morn- 
ing and  evening,  I  am  in  the  habit  of  giving  quinine  before  it  is 
expected  to  come  on,  and  when  it  is  fully  developed  I  recommend 
a  simple  saline  mixture,  cooling  drinks,  and  cold  sponging. 
Where  there  is  much  cerebral  excitement  it  is  well  to  give  the 
quinine  in  hydrobromic  acid. 


CHAPTER   YIII. 

TYPHOID    FEVER. 


Definition  and  variotis  meanings — Infantile  remittent  fever  and  typhoid  fever  synonymous 
terms — Symptoms,  cmirse,  and  progress  —  Complications  and  sequelce  of  typhoid  fever — 
Treatment — Diagnosis  of  typhoid  fever  from  meningitis — Acute  tuberculosis— Symptoins 
dependent  on  the  severity  of  the  fever  poison — Epistaxis — Scematuria. 

Typhoid  or  enteric  fever  is  distinguished  by  the  prevalence  of 
gastric  and  intestinal  symptoms.  It  has  received  the  name  of  in- 
testinal fever,  pythogenic  fever,  and  muco-enteritis.  Most  German 
writers  call  it  abdominal  typhus  (typhus  abdominalis).  In  ad- 
dition to  these  terms,  there  is  the  well-known  name  of  infantile 
remittent  fever. 

I  must  disavow  at  once  any  belief  in  infantile  remittent  fever  as 
caused  by  a  separate  and  distinct  poison,  or  that  the  disease  differs 
in  its  nature  or  causes  from  that  of  typhoid.  I  can  conceive  few 
greater  blunders  in  practical  medicine  than  to  consider  this  a 


84  DISEASES    OF   CHILDRElSr. 

separate  and  distinct  affection,  not  following  the  sanie  course  as 
tj'phoid  fever,  and  not  leading  to  the  same  complications.  To  me 
it  seems,  however,  that  there  is  a  condition  to  which  this  term  may 
he  applied  without  causing  confusion  ;  it  should  be  limited  to  the 
Ttiildest  cases,  which  usually  run  a  quick  course,  and  do  not  de- 
velop into  the  severe  and  unmistakable  typhoid. 

The  term  may  be  vague  and  ill -defined,  but  it  conveys  to  the 
minds  of  many  persons  a  form  of  mild  fever  arising  from  miasmatic 
influence  like  typhoid,  and  attended  witli  much  gastro-intestinal 
disturbance.  In  these  milder  cases  we  have  no  characteristic  rash, 
and  the  short  duration  of  the  fever  in  some  children  does  not  allow 
of  its  being  classed  under  the  name  of  a  specific  disease.  The 
pyrexia  is  due  to  a  depraved  condition  of  the  alimentary  canal,  of 
long  or  short  duration,  and  when  this  is  corrected  the  disease 
quickly  departs.  To  such  cases  as  these  the  term  typhoid  fever 
could  not  with  propriety  be  well  applied. 

I  would  not,  however,  mix  it  up  with  simple  febrile  disorder,  nor 
with  fever  symptomatic  of  worms,  dentition,  and  visceral  derange- 
ment, which  pass  away  as  quickly  as  these  conditions  are  remedied  ;* 
but  it  is  something  more  chronic  and  intractable,  lasting  only  a 
few  da^^s  in  some  instances,  whilst  in  others  it  has  the  duration 
and  all  the  attendant  complications  of  the  genuine  typhoid  state. 
To  these  milder  forms,  caused  by  the  imbibition  of  a  small  dose  of 
fever  poison,  I  wish  especially  to  draw  attention.  If  we  will  ac- 
cept the  term  with  this  understanding  it  cannot  mislead  us. 

In  the  nomenclature  of  diseases,  drawn  up  by  the  Royal  College 
of  Physicians  of  London  in  1869,  infantile  remittent  fever  is 
rightly  mentioned  as  synonymous  with  enteric  fever,  and  among 
most  medical  men  1  presume  its  close  relationship  to  this  fever  is 
now  settled.  Writers  in  France,  Germany,  and  Italy  acknowledge 
the  same  classification.  They  speak  of  infantile  remittent  fever  in 
children  as  being  the  same  as  typhoid  fever  in  the  adult,  but  inas- 
much as  they  give  it  this  name  they  certainly  recognize  some  dis- 
tinctive feature.  We  hear  members  of  our  profession,  especially 
country  practitioners,  speaking  of  remittent  fever  in  children  as  a 
distinct  disease,  and  I  have  found  the  prejudice  so  great,  and  the 
belief  so  strong,  that  it  has  not  been  possible  to  convince  them  of 
the  identity  of  the  two  affections.     My  main  object  will  be  to  show 

*  Vide  Febris  Ephemera. 


TYPHOID   FEVEE.  85 

that  this  remittent  fever,  in  its  severe  forms,  is  intimately  con- 
nected with  the  course  and  complications  of  typhoid  fever. 

Ty])hoid  fever  frequently  sets  in  insidiously,  initiated  by  chilliness 
or  slight  rigors,  frequent  and  soft  pulse ;  then  ensue  febrile  symp- 
toms and  thirst,  with  diarrhoea  and  abdominal  tenderness;  to  this 
succeed  tympanites  and  gurgling  in  the  right  iliac  fossa.  The  skin 
becomes  hot,  and  there  is  occasional  sweating.  From  the  seventh 
to  the  fourteenth  day  an  eruption  of  rose-colored  spots  appears  over 
the  abdomen,  there  is  headache  and  prostration,  followed  by  stupor 
and  delirium.  After  death  there  is  discovered  disease  of  the 
agminate  and  solitary  glands  of  the  ileum,  and  enlargement  of  the 
mesenteric  glands.  When  death  takes  place  early,  the  morbid 
changes  are  chiefly  found  in  the  small  intestines,  spleen,  mesenteric 
glands,  and  bronchial  raucous  membrane.  The  heart  may  contain 
coagula,  and  its  muscular  substance  be  soft  and  pale,  with  or  with- 
out incipient  molecular  decay.*  The  spleen  is  generally  enlarged 
in  the  first  or  second  week,  but  returns  to  its  normal  size  by  the 
third  or  fourth  week. 

Whether  we  call  this  disease  in  children  typhoid,  or  remittent 
fever,  it  comes  on  very  gradually  in  some  cases,  and  sets  in  with 
severity  in  others.  It  follows  a  course  in  children  similar  to  that 
in  adults.  In  the  mild  form  the  child  is  off  his  appetite  and  out 
of  sorts  for  some  days ;  he  complains  of  thirst,  is  fretful  and  irri- 
table, and  ceases  to  be  cheerful  or  to  take  pleasure  in  his  usual 
amusements;  his  nights  are  disturbed  and  unrefreshing;  the 
bowels  are  confined,  and  the  motions  dark  and  unhealthy,  so  as  to 
need  aperient  medicine,  or  they  may  be  loose  and  offensive  from 
the  onset.  Then  succeeds  heat  of  surface,  followed  by  perspira- 
tion and  a  lowering  of  temperature.  During  the  first  week  the 
abdomen  may  be  natural  in  shape,  and  free  from  tenderness  ;  but 
there  soon  follows  some  amount  of  tympanites,  and  pain  over  one 
or  both  iliac  regions,  when  pressure  is  applied  with  the  hancl.  In 
the  evening  there  is  a  febrile  exacerbation,  with  accelerated  pulse 
and  breathing,  the  lips  become  dry,  and  the  tongue  is  coated  on 
the  dorsum  with  a  whitish-yellow  fur.  There  may  be  two  exacer- 
bations in  the  twenty-four  hours,  but  commonly  there  is  only  one. 
It  is  from  the  recurrence  of  these  exacerbations  that  the  term 
"remittent"  is  derived.     During   the   night  the  child   becomes 

*  Yogel  on  Diseases  of  Children,  p.  177. 


86  DISEASES   OF   CHII.DREIS'. 

more  restless  and  disturbed;  he  is  wandering  and  talkative,  and 
the  cerebral  functions  may  be  sufficiently  disturbed  to  produce 
delirium ;  in  the  morning  he  looks  pale  and  exhausted,  but  im- 
proves during  the  day  till  evening  returns,  when  he  is  again  fever- 
ish and  drowsy,  and  this  may  happen  for  several  successive  nights. 
Sometimes  there  is  a  morning  exacerbation  (about  10  or  11  a.m.), 
and  this  has  scarcely  subsided  before  the  evening  paroxysm  sets  in. 
He  now  loses  flesh  rapidly,  and  is  dull  and  indifferent  to  all  that 
goes  on  around  him.  During  the  second  week,  but  seldom  before 
the  tenth  day,  fever-spots  make  their  appearance  on  the  abdomen, 
though  they  are  frequently  altogether  absent  or  few  in  number. 
The  eruption  is  of  a  light-rose  color,  scarcely  elevated  above  the 
surface,  disappearing  on  pressure  and  quickly  reappearing  when 
the  pressure  is  removed.  All  the  symptoms  increase  in  severity, 
and  the  pulse  may  reach  140  to  160  ;  the  tongue  is  more  heavily 
furred,  or  brownish  in  the  centre,  red  at  the  tip  and  edges  and 
contracted;  the  urine  is  scanty  and  high-colored, but  sometimes  it 
is  clear  throughout  the  fever,  and  alkaline  without  the  slightest 
turbidity ;  diarrhoea  is  continuous,  and  the  motions  are  of  a  yellow- 
ochre  color,  and  of  a  thin  pea-soup  consistence.  In  exceptionally 
severe  cases  blood  and  mucus  may  be  present,  and  when  so  they 
indicate  more  than  usual  ulceration.  About  the  beginning  of  the 
third  week,  in  favorable  cases,  the  symptoms  begin  to  decline  and 
a  general  amelioration  takes  place;  the  bowels  act  more  regularly 
and  become  more  natural,  thirst  diminishes,  and  the  pulse  loses  its 
frequency,  the  tongue  is  more  moist  and  clean,  and  the  evening 
paroxysm  diminishes.  The  child  resumes  a  more  cheerful  and 
healthy  appearance,  but  he  is  left  weak  and  emaciated.  When 
the  disease  sets  in  with  great  severity  from  the  onset,  it  is  accom- 
panied by  headache  and  vomiting,  the  child  rolls  his  head  to  and 
fro  on  the  pillow,  and  is  only  half  conscious  when  roused  to  answer 
a  question,  or  awakened  out  of  sleep  Many  of  the  symptoms  are 
similar  to  those  just  descpbed,  except  that  they  are  proportionately 
more  severe,  especially  the  evening  exacerbations  of  the  fever. 
There  is  difficulty  in  forming  a  diagnosis  at  the  beginning  of  the 
illness,  as  the  vomiting  and  cerebral  symptoms  may  lead  to  the 
inference  that  the  brain  is  the  organ  primarily  at  fault.  The 
drowsiness  is  sometimes  extreme,  and  when  there  is  the  additional 
symptom  of  constipation  we  may  be  reasonably  mistaken  in  fixing 
the  true  seat  of  mischief.     But  soon  the  vomiting  ceases,  and  by 


TYPHOID   FEVEE.  87 

the  second  or  third  day  the  peculiar  heavy  aspect  of  fever  is  recog- 
nized, and  the  child  sinks  into  a  state  of  stupor  or  indifference. 
The  skin  becomes  hot  and  dry,  and  the  temperature  runs  up  to 
103°  or  even  to  105°.  When  it  reaches  the  latter  height  at  an 
early  stage  of  the  illness  we  may  generally  rest  satisfied  that  the 
symptoms  are  not  attributable  to  meningitis.  Fever-spots  may  now 
he  looked  for,  but  their  presence  does  not  seem  to  bear  any  relation 
to  the  mildness  or  severity  of  the  fever,  and  they  are  sometimes 
absent  altogether.  The  pulse  is  always  frequent,  and  if  it  con- 
tinues so  is  to  be  regarded  as  an  important  symptom.  In  some 
children,  whose  nervous  irritability  is  more  marked,  it  will  exceed 
140,  and  remain  so  as  long  as  the  fever  and  temperature  continue 
high.  It  may  run  up  to  180  and  be  too  rapid  to  be  counted.  "  An 
intermittent  pulse  seldom  occurs  in  children,  and  I  do  not  remem- 
ber to  have  ever  met  with  a  dicrotic  pulse  in  children  under  ten 
years  of  age."'^  This  remark  requires  some  qualification.  An  ir- 
regularly intermittent  pulse  is  common  in  the  neurosal  affections 
of  children  when  there  is  no  valvular  disease  of  the  heart. 

About  this  time  (second  week)  there'  is  often  hacking  cough  and 
hurried  respiration.  There  is  constantly  to  be  recognized  some 
rhonchus  or  coarse  crepitation  over  the  jjosterior  surface  of  the 
luno;s,  even  if  auscultation  reveals  nothino;  in  front.  If  the  disease 
has  lasted  long  we  shall  almost  invariably  detect  these  signs,  or 
even  crepitant  rhonchus  with  a  low  degree  of  pneumonia.  If  the 
abdomen  has  been  hitherto  soft  and  free  from  tenderness,  a  sense 
of  discomfort  and  pain  is  complained  of  at  this  stage,  and  there  is 
tympanites  with  gurgling,  and  the  bowels  act  five  or  six  times  in 
the  twenty-four  hours ;  the  tongue  is  more  thickly  coated,  and 
there  is  a  red  streak  in  the  centre,  and  in  the  course  of  the  next 
few  days  it  is  glazed,  smooth,  and  red,  whilst  the  gums  are  dry. 
During  the  second  week  the  stupor  becomes  more  profound,  or 
active  delirium  appears,  and  the  child  is  noisy  at  night  and  attempts-, 
to  get  out  of  bed  ;  he  is  unconscious  of  all  that  goes  on  around^ 
him,  and  the  evacuations  are  passed  involuntarily.  Epistaxis  ia- 
not  uncommon.  In  a  few  cases  the  bladder  becomes  distended 
and  the  urine  dribbles  away.  On  examination  it  may  be  found 
albuminous.  There  may  be  even  convulsions  and  noisy  delirium^ 
but  the  insensibility  is  not  so  profound  as  that  generally  met  witk 
in  brain  affections,  and  the  morbid  stupor  of  fever  is  characteristic. 

*  Vogel,  On  Diseases  of  Children,  1874,  p.  180. 


88  DISEASES    OF    CHILDREN. 

In  fever  we  do  not  as  a  rule  witness  the  strabismus  and  irregu- 
larity of  the  pupils,  nor  the  screwing  up  of  the  eyelids  as  in  cere- 
bral disease.  The  child  may  be  noticed  to  pick  his  lips  and  nose, 
and  make  them  bleed,  and  there  may  be  subsultus.  By  this  time 
there  is  great  emaciation,  and  the  child  is  so  reduced  that  it  seems 
beyond  the  hope  of  recover3\*  By  the  seventeenth  day,  or  the 
close  of  the  third  week,  some  signs  of  amendment  in  returning 
intelligence  are  observed,  and  the  pulse  becomes  less  frequent, 
whilst  the  tongue  begins  to  be  moist,  and  the  sordes  disappear.  If 
no  improvement  sets  in  the  vital  powers  become  more  and  more 
depressed,  the  typhoid  condition  increases,  and  the  child  sinks  from 
exhaustion.  This  is  most  likely  to  happen  about  the  fourteenth 
or  fifteenth  day,  but  it  may  be  protracted  to  the  fourth  or  fifth 
week,  or,  indeed,  indefinitely  prolonged,  according  to  the  complica- 
tions that  are  present  in  each  particular  case.  When  death  takes 
place  during  the  first  week  of  the  fever  it  is  generally  due  to  cere- 
bral disturbance  or  some  other  serious  complication,  as  epistaxis 
or  intestinal  haemorrhage.    The  latter  condition  is  rare  in  children. 

Of  the  sequelfe  of  typhoid  fever  in  children  we  may  mention 
diarrhoea,  inflammation  of  the  parotid  gland,  and  tuberculosis. 
Dr.  Clifl:brd  Albutt  has  pointed  out  that  the  mesenteric  glands 
are  often  so  injured  by  typhoid  fever  that  nutrition  is  very  much 
impaired;  and  it  is  under  these  circumstances  that  tuberculosis  is 
apt  to  show  itself,  whilst  the  period  of  convalescence  renders  the 
constitution  liable  to  measles,  scarlatina,  and  whooping-cough. 
The  mortality  is  only  5  to  10  per  cent.f 

In  proportion  to  the  severity  of  the  fever  convalescence  is  rapid 
or  slow.  In  severe  typhoid  there  is  great  emaciation  and  muscu- 
lar prostration,  lasting  many  weeks,  and  the  child  is  greatly  re- 
duced in  flesh  and  strength,  but  bedsores  are  seldom  seen. 

Meigs  and  Pepper  say  that  typhoid  fever  may  attack  children 

*  "  Wliether  the  musciilar  wasting  in  fever  is  the  cause  of  an  increased  temperature, 
or  tlie  increased  temperature  melts  down  the  muscular  structures,  may  not  be  positively 
affirmed,  but  there  exists  no  doubt  as  to  the  fact.  After  a  severe  pyretic  affection, 
the  muscles  of  the  limbs  are  often  wasted  to  an  extent  quite  surprising  when  compared 
to  the  adij)Ose  layers.  The  lax  and  shrunken  Jiand  betokens  the  diminution  in  the 
bulk  of  the  interossei  and  otJier  muscles.  In  liectic  fever  the  muscles  seem  sometimes 
to  have  almost  entirely  disappeared  at  death,  tlie  patient  being,  as  it  is  called,  '  only 
skin  and  bone.'" — Dr.  Miliier  l^^otliergill,  "On  tlie  Typlund  Condition,"  Edinburijh 
Jledical  Journnl,  September,  1873. 

f  Meigs  and  Pepper,  Diseases  of  Children,  1874,  p  832. 


TYPHOID    FEVER.  89 

luider  two  years  of  age,  or  as  early  as  the  eighteenth  or  twentieth 
month,  but  it  must  be  acknowledged  that  the  disease  is  rare  under 
five  years  of  age.  A  ease  is  recorded  by  Dr.  Dunbar  Walker,  seen 
in  consultation  with  Dr.  West,  of  "enteric  fever  in  a  child  fifteen 
mouths  old,"*  and  Dr.  AViltshire  also  mentions  having  seen,  with 
Dr.  Walters,  of  Reigate,  "a  well-marked  example  in  an  infant 
aged  six  months."! 

The  morbid  appearances  when  the  disease  ends  fatally  are  chiefly 
seen  at  the  lower  end  of  the  ileum,  the  most  entensive  mischief 
being  found  near  the  ileo-C£ecal  valve,  where  there  is  shown  a  ten- 
dency to  destruction  of  the  mucous  membrane,  and  ulceration  or 
even  sloughing,  or  perforation  of  the  peritoneal  coat.  The  glands 
of  Peyer's  patches  take  on  the  appearance  of  vesicles  or  pustules, 
and  subsequently  they  burst  and  produce  an  ulcer,  with  oval  or 
irregular  outline,  havino;  thin  and  undermined  edges.  The  ileum 
is  the  chosen  seat  of  these  ulcers,  but  they  may  be  seen  scattered 
through  all  parts  of  the  intestine,  large  as  w^ell  as  small.  It  is 
common  to  meet  with  enlaro-ement  and  softening  of  the  mesenteric 
glands,  and  in  severe  and  rare  instances  they  may  take  on  suppu- 
ration. 

Treatment. — During  the  gradual  approach  of  the  disease,  when 
there  is  thirst  and  loss  of  appetite,  the  child  must  not  be  tempted 
to  take  food  which  it  cannot  digest.  Thirst  should  be  relieved 
by  small  draughts  of  cold  water,  or  toast  and  water,  about  a  table- 
spoonful  at  a  time,  and.  a  simple  saline  mixture  of  citrate  of  pot- 
ash, or  a  mixture  of  nitrate  of  potash  with  a  few  grains  of  sulphate 
of  magnesia,  if  the  bowels  are  confined  (Form.  8).  For  the  first 
few  daj'S  scarcely  anything  but  cold  water  is  required.  If  the 
secretions  are  dark  and  offensive,  an  alterative  powder  of  hydrar- 
gyrum cum  creta  with  a  few  grains  of  rhubarb  will  be  necessarj^ 
or  the  syrup  of  senna  and  rhubarb,  or  even  castor  oil,  should  there 
be  discomfort  or  pain  in  the  abdomen.  When  there  is  tenderness 
of  the  abdomen,  a  warm  poultice  is  comforting ;  and  if  there  is 
pain  Dr.  West  recommends  a  few  leeches,  which  I  have  never 
found  necessary,  and  I  should  try  other  means  before  resorting  to 
them.  The  excitement  and  restlessness  at  night  may  be  greatly 
relieved  to  the  advantage  of  the  patient  by  bromide  of  potassium 
alone,  or  in  combination  with  hydrate  of  chloral.  They  have 
proved  of  such  value  in  my  hands  in  all  cases  of  wakefulness  from 

*  Brit.  Med.  Journal,  vol.  i,  1879,  p.  347.  f  Ibid.,  vol.  i,  1879,  p.  427. 


90  DISEASES    OF    CHILDREN'.  ,    . 

nervous  exhaustion  that  I  recognize  them  as  valuable  calmatives 
in  fever.  Dr.  West  speaks  highly  of  a  combination  of  tartar 
emetic  and  opium.  "A  draught  containing  five  minims  of  lauda- 
num, and  a  quarter  or  a  third  of  a  grain  of  tartar  emetic,  will  be 
a  suitable  anodyne  for  a  child  of  five  years  old,  and  may  be  re- 
peated night  after  night  with  almost  magical  efl'ect."*  One  drop 
of  laudanum,  or  something  less,  for  each  year  of  the  child's  age, 
in  restlessness  and  excitement,  will  often  induce  refreshing  sleep ; 
and  it  may  be  repeated,  should  circumstances  appear  to  demand 
it,  without  giving  rise  to  any  bad  effects.  If  there  be  much  heat 
of  scalp  and  the  vessels  are  full  about  the  temples,  and  the  con- 
junctivae injected  ;  if  the  delirium  is  wild  and  the  excitement  fierce, 
then  we  ought  certainly  to  shave  the  head,  and  apply  four  or  six 
leeches.  These  symptoms  often  succumb  to  the  local  abstraction 
of  blood,  and  life  has  thus  in  many  cases  been  saved.  The  head 
symptoms  that  occasionally  supervene  in  an  advanced  stage  of  the 
disease  are  very  ominous,  and  require  counter-irritation  ;  they  are 
often  attended  with  squinting,  and  there  is  some  amount  of  ob- 
scure meningitis  with  eftusion,  which  may  ultimately  terminate 
in  acute  hydrocephalus. 

The  temperature  of  the  room  should  not  exceed  65°,  and  all 
unnecessary  articles  of  furniture  and  luxury  should  be  removed; 
the  clothing  should  be  light,  the  head  shaved  or  the  hair  cut  short, 
and  the  head  elevated  on  the  pillow. 

During  the  second  week,  when  the  vital  powers  require  support, 
milk,  beef  tea,  and  chicken  broth  will  be  needed ;  and,  if  there  is 
diarrhoea,  milk,  arrowroot,  and  rice-water,  flavored  with  cinnamon, 
must  be  substituted  for  animal  broths.  Milk  is  apt  to  be  overrated 
in  fever,  for  where  the  bowels  are  loose  and  irritable,  and  the  stom- 
ach weak,  as  we  expect  to  find  it  in  the  first  week  or  two  of  the 
fever,  the  milk  is  too  heavy  to  be  digested,  and  the  curd,  acting 
as  an  irritant  when  the  fluid  portion  is  absorbed,  provokes  diar- 
rhoea, and  even  keeps  it  up  if  present.  It  should  therefore  be  di- 
luted with  seltzer  water,  or  lime-water,  and  in  many  cases  it  may 
be  replaced  by  beef  tea,  or,  what  is  better,  barley-water,  beef  tea 
being  apt  to  induce  and  keep  up  purging.  When  diarrhoea  is 
troublesome,  a  grain  or  two  of  Dover's  powder  at  bedtime,  or  a 
starch  enema  with  a  few  drops  of  opium,  or  bismuth  will  check 
the  irritation.     A  grain  of  acetate  of  lead  with  acetic  acid  every 

*  West  on  Diseases  of  Children,  1859,  p.  392. 


TYPHOID    FEVER.  91 

three  or  four  hours  is  sometimes  of  service  (Form.  29).  A  mixture 
containing  rhatany  root*  is  an  excellent  remedy  after  each  evacu- 
ation, and  the  child  may  be  allowed  a  little  port  wine  in  arrow- 
root. 

Stimulants  are  not  often  required  under  ten  years  of  age  if  the 
child  can  digest  sufficient  nourishment,  but  cases  occasionally 
occur  where  life  has  been  saved  by  a  free  exhibition  of  them.  A 
teaspoonful  of  brandy  every  three  or  four  hours  in  water  or  thin 
arrowroot  will  restore  the  tone  of  the  nervous  system,  and  sup- 
port the  faltering  circulation.  Alcohol  proves  serviceable  by 
dilating  the  cutaneous  capillaries,  and  encouraging  perspiration. 

In  the  shape  of  medicine,  a  few  drops  of  dilute  hydrochloric 
acid  with  spirit  of  chloroform,  as  in  the  case  of  adults,  will  be 
usefult  if  there  is  no  abdominal  pain  or  discomfort  ;  and  in  low 
febrile  conditions,  where  there  is  no  diarrhcea,  quinine  with  phos- 
phoric acid  is  an  excellent  measure.* 

Diagnosis. — The  cerebral  complications  of  typhoid  fever  in 
children  are  most  important. §  Like  the  bowels  and  the  lungs, 
the  brain  is  liable  to  be  attacked  in  the  course  of  typhoid  fever,  and 
young  patients  more  than  those  of  mature  years,  are  very  prone 
to  be  carried  off  by  cerebral  complications.  The  febrile  process 
once  established  creates  disturbance  and  excitement  in  the  nervous 

*  Formula  4 : 

R.  Tinct.  kramerife,        . ^iij 


"Kxx 
S-ss. 
5iv.— M. 


Liquor  opii  sed.,        .... 

Spt.  chloroform,         .... 

Syr.  zingiberis,  ..... 

Aquam  ad         ..... 

A  dessertspoonful  after  each  action  of  the  bowels.     For  children  from  five  to  eight 
years  of  age. 
t  Formula  5 : 

R.    Acid,  hydrochl.  dil.,         .         .         .         .         .         .         .     "JJxl 

Spt.  chloroform,       ........     "Xxx 

Syr.  rosfe,         .         .         .         .         .         .         .         .         .     5ss. 

Aquam  ad        ........         .     §iv. — M. 

A  dessertspoonful  every  four  hours.     I-  or  children  from  five  to  eight  years  of  age. 
X  Formula  6  : 

R.    Quinise  sulph.,         ........     gr.  iv 

Acid,  phosph.  dil.,  ........     ^j 

Syrupi,  .         .         .         .         .         .         .         .         .     ^ss. 

Aquam  ad       ........         .     .fiv. — M. 

A  dessertspoonful  three  or  four  times  a  day.     For  children  from  five  to  eight  years 
of  age. 

§  See  the  abstract  of  a  paper  on  this  subject  read  before  the  Harveian  Society  by  the 
author.     Brit.  Med.  Jour.,  Feb.  14th,  1S75,  p.  122. 


92  DISEASES    OF    CHILDREN. 

system  at  a  time  when  its  active  growth  and  rapid  development 
are  ill  calculated  to  bear  this  extra  strain.  If  simple  inflamma- 
tion of  the  brain  comes  on  now  and  then  in  healthy  children,  I 
think  it  may  occur  during  the  progress  of  typhoid  fever  in  rare 
and  exceptional  cases.  The  blood  is  changed,  the  nervous  system 
is  excited  or  depressed  at  one  stage  or  another,  and  the  functions 
of  assimilation  are  perverted  or  destroyed,  and  efiete  matters  from 
the  decomposed  tissues  are  not  properly  eliminated  from  the 
system.  Setting  aside  the  injurious  etfect  which  the  circulation 
of  poisoned  blood  at  an  elevated  temperature  must  have  on  the 
nervous  centres,  there  seems  no  satisfactory  reason  why  the  cere- 
bral changes  should  be  restricted  to  congestion  of  the  vessels,  or 
simple  vascularity  of  the  membranes. 

Xow,  it  should  be  fully  understood,  and  experience  confirms  the 
truth  of  the  statement,  that  vascularity  of  the  cerebral  mem- 
branes is  by  no  means  infrequent  in  persons  dying  from  typhoid, 
w^iere  the  brain  has  escaped  altogether  during  the  progress  of  the 
disease.  If  the  lungs  are  involved,  as  they  frequently  are  in 
typhoid,  and  there  is  any  amount  of  pneumonia,  or  interference 
with  the  pulmonary  circulation ;  if  the  heart  grows  feeble,  from 
increasing  exhaustion  of  the  j^atient,  and  its  cavities  become  in 
any  way  oppressed,  then  congestion  of  the  brain  orit^  membranes 
will  he  frequently  found  after  death  ;  the  cause  has  been  mechan- 
ical, and  we  may  term  the  condition  one  of  "  passive  congestion." 
Ko  relation  can  be  established  between  the  cerebral  symptoms  and 
the  amount  of  vascularity  which  the  membranes  of  the  brain 
reveal.  If  we  judge  from  the  character  of  the  delirium,  or  the 
convulsions,  and  the  general  insensibility  of  the  patient,  that  these 
symptoms  indicate  excessive  congestion  or  inflammatory  action, 
we  shall  be  deceived,  and  errors  of  diagnosis  wnll  certainly  lead  us 
into  errors  of  practice. 

The  diagnostic  symptoms  of  meningitis  and  typhoid  fever  are 
plainly  drawn  in  our  textbooks  ;  but  those  who  have  seen  much 
of  the  cerebral  and  abdominal  diseases  of  young  children  must 
admit  the  frequent  difficulties  that  beset  their  path.  The  worst 
cases  of  all  for  diagnosis  are  those  in  which  a  strumous  child  is 
seized  with  tubercular  disease  in  the  abdomen  with  diarrha3a  and 
other  intestinal  symptoms ;  there  is  nothing  to  call  attention  to 
the  brain  till  coma  or  convulsion  sets  in.  Still,  the  ai:)proach  of 
meningitis  is  slower  and   more  insidious  ;  it  is  less  severe  than 


TYPHOID    FEYEE.  93 

typhoid  fever,  and  at  an  early  stage  very  rarely  presents  tlie  high 
temperature  of  the  latter  atfectiou,  which  is  a  diagnostic  sign  of 
great  value. 

We  cannot,  therefore,  invariably  separate  typhoid  fever  in  young 
children,  characterized  by  a  distinctly  remittent  type,  from  cere- 
bral meningitis,  especially  when  the  child  is  under  live  years  of 
age.  The  symptoms  of  one  disease  or  the  other  must  predominate 
before  we  can  decide  with  which  we  are  dealing.  Usually  the 
bowels  are  constipated  in  the  cerebral  disorder,  and  vomiting 
comes  on  without  cause,  whether  the  stomach  contains  food  or 
not ;  the  belly  is  normal  or  retracted,  the  pulse  less  frequent,  and 
liable  to  irregularity  in  force  and  frequency.  Above  all,  the  tem- 
perature in  meningitis  is  generally  elevated  towards  the  decline  of 
the  complaint,  and  only  runs  high  at  an  early  period  in  excep- 
tional cases.  The  ophthalmoscope  is  another  aid  to  diagnosis  iu 
obscure  cases.* 

If  the  symptoms  are  mixed  together  in  various  degrees,  and 
there  is  irritation  of  the  digestive  organs,  and  cerebral  congestion 
or  inflammation,  then,  if  with  severe  diarrhoea  there  are  thin, 
ochrey,  and  slimy  stools,  heat  of  skin,  loss  of  appetite,  thirst,  and 
flushed  countenance,  we  say  this  is  a  case  of  fever ;  but  if  there 
supervene  in  a  few  days  uneasy  gestures,  strabismus,  loss  of  con- 
sciousness, picking  of  the  lips  and  nose,  retching  or  vomiting,  then 
we  infer  that  the  brain  has  been  attacked  in  course  of  the  fever, 
and  the  symptoms  are  the  result  of  exhaustion  or  overexcitement. 

Our  diagnosis  must  mainly  rest  on  the  order  in  which  these 
symptoms  have  occurred.  We  must  not  dwell  too  much  on  the 
fever  process,  and  set  down  the  vomiting  and  carebral  symptoms 
to  gastric  disturbance,  whilst  the  brain  has  been  slowly  and  im- 
perceptibly going  wrong,  and  is,  perhaps,  the  chief  source  of 
trouble. 

If  the  physician  is  called  to  see  the  case  early,  and  an  exact 
account  of  the  mode  of  invasion  has  been  furnished,  his  judgment 
will  seldom  lead  him  wrong,  if  he  carefully  weighs  the  evidence  on 
both  sides,  and  notes  the  absence  or  prevalence  of  fever  in  the  same 
house. 

Acute  phthisis  or  tuberculosis  may  be  mistaken  for  typhoid 
fever.     A  quick  pulse,  hurried  respiration,  circumscribed  flushing 

*  See  Chap.  XLII,  "  Diseases  of  the  Brain — Simple  Meningitis  and  Tubercular 
Meningitis." 


94  DISEASES   OF   CHIT.DREK. 

of  the  cheeks,  emaciation,  delirium,  mucous  rales  iu  the  chest,  and 
high  temperature  are  common  to  both  aftectious.* 

In  some  adults  suffering  from  tj^phoid  fever  we  witness  the 
evening  flush  on  the  cheek  with  great  regularity  and  persistence. 
In  other  cases,  with  all  the  symptoms  precisely  similar,  the  face  is 
pallid,  and  without  the  faintish  blush.  This  points  to  a  recurrence 
of  the  febrile  condition  with  greater  force,  and  often  indicates,  as 
the  disease  advances,  serious  local  changes,  either  in  the  intestines, 
thorax,  or  brain.  So  far  it  is"  a  symptom  of  grave  import  when  it 
recurs  at  a  late  period  of  the  fever.  The  periodical  flushing  is  not 
peculiar  to  fever  as  fever.  It  belongs  to  the  nervous  system,  and 
may  ensue  from  many  causes.  The  nervous  system  is  highly  hn- 
pressible  in  children,  and  their  diseases  have  a  great  tendency  to 
remission.  Witness  the  flushing  of  the  face  and  heat  of  head  in 
some  of  the  cerebral  afiiections  of  young  subjects,  coming  and 
going  like  an  attack  of  ague.  Or,  again,  in  dentition,  nothing  is 
more  common  than  for  the  child  to  wake  up  restless,  with  hot  head 
and  flushed  cheeks.  Common  gastric  disturbance  will  cause  the 
same  symptoms,  which  vanish  with  an  active  purge.  Fever  affects 
the  nervous  system  through  the  poisoned  state  of  the  blood,  and 
the  depression,  the  reaction,  and  the  subsidence  all  depend  upon  it. 

We  know  that  this  is  the  true  explanation  of  the  dangerous  con- 
gestions and  inflammation  of  the  liver,  lungs,  or  brain,  that  are 
liable  to  occur  in  the  progress  of  fever,  adding  to  our  difficulties, 
and  taking  us  out  of  the  prescribed  course  to  meet  such  serious 
complications  by  local  depletion,  diuretics,  stimulants,  and  so 
forth. 

May  we  not  fairly  come  to  the  conclusion  that  there  are  degrees, 
nay,  even  varieties  of  fever  originating  from  a  common  cause,  and 
that,  whilst  it  is  the  exception  to  meet  with  a  case  where  there  is 
any  difficulty  in  recognizing  the  variety  before  us,  we  sometimes 
see  cases  in  which  the  symptoms  are  not  sufficiently  defined  to 
enable  us  to  say  what  form  of  fever  we  have  to  deal  with.  Thus, 
the  remittent  character  of  the  disease  is  very  well  marked  in  some 
cases,  but  to  this  are  added  symptoms  which  some  authors  have 
enumerated  as  belonging  to  a  distinct  afl:ection  they  call  gastric 
fever,  and  subsequently  symptoms  which  we  regard  as  belonging 
to  typhoid  fever.    It  appears  certain  that  infantile  remittent  fever, 

*  See  Chap.s.  XXXIX,  XL,  "  Oa  Tuberculosis,"  and  "On  Plitliisis  Pulmoualis." 


TYPHOID    FEVER.  95 

well  developed,  embraces  both  tbese  types,  or  ratlier  that  identical 
symptoms  frequently  supervene. 

There  is,  however,  a  caprice  in  fever  which  should  put  us  on 
our  guard.  The  fever-poison,  assailing  the  system  for  weeks, 
works  such  changes  in  the  blood  and  tissues  of  the  body,  that  we 
can  never  be  certain  we  have  landed  a  case  of  fever  in  safety,  so 
long  as  there  is  much  departure  from  the  standard  of  general 
health.  Some  of  the  worst  cases  of  epistaxis,  hsematuria,  and 
bleeding  from  the  bowels  have  occurred  when  patients  have  be- 
come convalescent  from  fever,  with  clean  tongue,  regular  pulse, 
and  ffood  digestion.  If  we  have  reason  to  think  that  the  tone 
and  quality  of  the  blood  have  suffered  much,  either  from  the  fever 
itself  or  the  remedies  employed  to  reduce  it,  we  should  as  early  as 
possible  begin  such  treatment  as  shall  gradually  replace  the  solid 
constituents  that  have  been  destroyed.  The  haemorrhages  are  not 
altogether  confirmatory  of  the  typhoid  character  of  the  disease. 
Any  causes  that  tend  to  bring  about  an  impoverished  condition 
of  the  blood  may  produce  the  complication.  In  scurvy  and  pur- 
pura, and  fevers  of  a  low  type  (in  all  of  which  serious  haemorrhage 
may  occur),  the  changes  in  the  chemical  composition  of  the  blood 
are  nearly  identical.  Intestinal  haemorrhage  occurs  in  typhoid 
fever  without  ulceration  ;  it  is  met  with  in  cases  described  by  some 
writers  under  the  vague  head  of  gastric  fever.  Sometimes,  though 
rarely,  a  patient  succumbs  to  haemorrhage  in  typhus  also,  and  it 
would  seem  that  the  fever-poison — whether  typhus  or  typhoid^  but 
more  especially  the  latter,  and  in  the  more  severe  remittent  forms 
which  merge  into  the  continued  type — leads  to  the  same  issue. 

In  one  case  you  will  find  rose-colored  maculae  on  the  chest  and 
abdomen,  and  the  tongue  red  and  papillas  elongated.  There  is  no 
tenderness  of  the  belly  and  no  diarrhcEa.  In  another  case  the 
fever  is  of  a  very  low  type,  partly  from  the  severity  of  the  poison, 
and  partly  from  the  age  and  constitution  of  the  patient.  The 
teeth  are  dry,  the  tongue  is  covered  with  sordes,  but  there  is  no 
diarrhcea.  On  inspection  after  death  ulceration  is  found  in  the 
lower  part  of  the  ileum.  We  meet  with  another  case  in  which 
there  is  a  plentiful  eruption  of  rose-colored  spots,  but  there  is  no 
diarrhoea ;  on  the  contrary,  there  is  constipation,  and  the  bowels 
are  diflicult  to  move.  In  another  case  there  are  fever-spots  and 
severe  headache.  In  another,  delirium  at  night,  severe  bowel  ir- 
ritation, and  rose-colored  spots.     These  cases,  and  they  are  not 


96  DISEASES    OF    CHILDREN. 

infrequent,  tend  to  show  that  the  symptoms  are  not  always  alike. 
We  cannot  say  that  a  case  of  fever  is  not  typhoid  because  there 
exists  no  diarrhoea,  and  we  cannot  predict  that  there  exists  no  ul- 
ceration because  there  is  constipation.  We  are  accustomed  to 
think  that  if  the  bowels  are  quiet  in  fever  the  patient  has  a  good 
chance  of  doing  well,  that  the  intestinal  canal  is  at  all  events  free 
from  any  lesion  ;  but  what  I  think  is  a  surer  sign  of  the  mucous 
membrane  being  healthy  is  a  normal  state  of  the  evacuations, 
without  the  offensive  odor  th-at  is  present  whenever  there  is  ulcer- 
ation. How^ever  well  cases  may  be  progressing  the  general  health 
is  liable  to  break  down  unexpectedly  by  further  contamination  of 
the  blood,  and  the  entry  into  the  veins  of  infectious  particles  from 
the  ulcerated  glands  in  the  intestines.  Mere  quietude  of  the 
bowels  is  not,  as  I  have  just  said,  any  proof  that  the  glands  have 
escaped.  Perfect  uniformity  in  the  order  of  symptoms  does  not 
occur  ;  diseased  action  is  not  uniform.  It  would  be  neither  a  safe 
nor  a  scientific  hypothesis  to  lay  down  the  rule  that  all  diseases 
possess  a  uniform  phalanx  of  symptoms.  This  is  modified  and  in- 
fluenced by  a  variety  of  circumstances.  There  is  a  simple  form 
of  fever,  and  a  severe  form  of  fever.  Both,  so  far  as  our  present 
knowledge  goes,  are  intimately  allied,  but  one  is  transient  and 
slight,  and  the  other  is  severe  and  dangerous. 

To  go  a  step  further  in  the  same  direction,  it  would  appear  that 
the  cases  described  under  the  head  of  gastric  fever  and  typhoid 
fever  are  one  and  the  same  in  their  nature,  progress,  and  termina- 
tion. The  stomach  may  be  more  involved  at  one  time  than  at 
another,  as  evidenced  by  the  prominent  papillce  of  the  tongue,  and 
the  gastric  disturbance  and  vomiting,  but  it  is  the  same  fever  not- 
withstanding. 

Let  it  also  be  borne  in  mind  that  constitutional  power  varies  as 
much  as  it  influences  the  course  of  a  disease.  Vitality  is  stronger 
and  resistance  is  greater  in  some  persons  than  in  others.  The  de- 
gree of  local  change  discovered  after  death  is  often  slighter  than 
is  proved  to  have  been  present  in  cases  that  have  recovered.  Be- 
cause some  diseases  end  fatally,  we  are  not  necessarily  to  flnd 
tangible  evidence  of  the  cause  of  death  on  dissection.  To  some 
constitutional  idiosyncrasy — apart  from  organic  change  or  the 
effect  of  specific  poison  on  the  blood  and  nervous  system — we  must 
often  ascribe  the  tendency  to  sink;  so  we  must  also  regard  as  a 


SPECIAL    ERUPTIVE    FEVERS.  07 

mystery  that  tenacity  of  life  which  remains,  when  all  hope  of 
saving  it  has  apparently  passed  away. 


CHAPTER   IX. 

SPECIAL  ERUPTIVE  FEVERS. 

Their  dassif  cation  and  general  sxjmptoms — Vaccinia — Varicella — Character  of  the  eruption 
— Diagnosis  from  small-pox — Treatment. 

The  special  eruptive  fevers  of  childhood  are  vaccinia,  or  cow- 
pox;  varicella,  or  chicken-pox;  variola,  or  small-pox;  rubeola, 
or  measles  ;  scarlatina,  or  scarlet  fever.  They  are  all  due  to  the 
reception  of  a  poison  into  the  system,  which,  after  a  variable  pe- 
riod, sets  up  tolerably  uniform  constitutional  symptoms.  There 
are  shivering  and  rigors,  or  even  convulsions,  cold  along  the  spine, 
loss  of  appetite,  headache,  languor,  and  disturbed  sleep ;  then  re- 
action comes  on,  followed  by  fever,  heat  of  skin,  and  the  specific 
eruption.  These  are  the  chief  symptoms  which  mark  the  onset 
of  the  exanthemata.  They  often  prevail  as  epidemics,  and  these 
present  very  opposite  characters  in  the  degree  of  vascular  action 
and  the  power  of  resistance.  Though  some  epidemics  are  mild, 
they  are  as  a  rule  more  severe  than  those  of  sporadic  occurrence, 
and  the  severity  of  the  attacks  and  their  complications  depend  on 
age  and  constitution  ;  upon  hygienic  conditions,  and  the  season  of 
the  year.  If  the  health  is  lowered  by  previous  illness  they  attain 
greater  force,  and  the  mode  of  early  treatment  may  determine  the 
result.  They  pursue  a  determined  course,  and  active  interference 
is  sometimes  more  injurious  than  when  the  unaided  powers  of 
nature  are  left  alone,  for  in  this  way  it  is  possible  to  invite  various 
affections  more  dangerous  than  the  original  malady.  The  exan- 
themata generally  attack  persons  only  once  in  life,  and  that  at  an 
early  period.  Scarlet  fever  is  the  most  likely  of  these  diseases  to 
happen  a  second  time,  and  it  is  the  occasional  accompaniment  of 
measles.  Small-pox  and  measles  may  also  be  united  in  the  same 
individual ;  and  a  severe  attack  of  whooping-cough  may  set  in  be- 
fore the  latter  has  departed. 

Vaccinia,  Cow-pox,  or  Vaccination. — The  virus  of  cow-pox  when 
introduced  into  the  system  produces  a  specific  disease,  only  modi- 

7 


98  DISEASES    OF    CHILDREN. 

fied  by  its  passage  through  the  cow,  or  one  of  the  lower  animals. 
Vaccination  so  induced  is  protective  against  variola  or  small-pox. 
Cow-pox  is  a  vesicular  disease,  occurring  chiefly  on  the  teats  and 
udders  of  cows  ;  it  is  natural  to  them,  and  as  a  disease  of  spon- 
taneous origin,  occurs  almost  exclusively  to  the  milch  cow,  and 
follows  a  uniform  and  definite  course.  About  the  fourth  day  of 
invasion  a  few  red  and  tender  pustules  appear  on  the  teats  and 
udder,  which  change  into  vesicles,  and  pass  through  the  same 
stages  as  in  man.  From  the  friction  used  in  milking,  the  vesicles 
burst,  and  the  lymph  which  exudes  sets  up  similar  sores  on  the 
milker's  hands,  and  in  this  way  the  disease  is  conveyed  to  other 
animals  in  the  dairy  who  were  previously  well  and  healthy. 

After  successful  vaccination  there  is  nothing  certain  to  be 
observed  till  the  third  day,  when  a  small  red  nodule  is  noticed ;  on 
the  fifth  day  an  oval  or  circular  vesicle  is  seen,  depressed  in  the 
centre,  and  containing  a  little  lynmh.  There  may  be  as  many 
spots  as  punctures  a  day  or  two  before,  but  in  many  cases  we 
cannot  say  they  are  due  to  the  virus.  On  the  eighth  day  the 
vesicle  is  increased  and  threatens  to  burst,  the  centre  is  depressed, 
and  there  is  a  large  quantity  of  transparent  fluid.  The  vesicle  is 
at  its  highest  state  of  perfection ;  the  skin  for  some  distance 
around  it  is  inflamed  of  a  rosy  hue,  and  the  subjacent  areolar  tissue 
is  hard,  tender,  and  painful.  The  child  is  fretful  and  feverish,  and 
his  nights  restless  and  disturbed.  On  the  tenth  or  the  eleventh 
day  the  areola  has  extended,  and  the  greater  part  of  the  arm 
may  be  erj'^thematous.  If  the  vesicle  has  not  been  opened  it  now 
bursts,  and  the  centre  dries  into  a  hard  dark  scab,  and  falls  ofl:' 
about  the  twenty-first  day,  leaving  a  deep  circular  depression  or 
cicatrix,  with  several  pits  or  dots,  having  a  whitish  or  more  pearly 
look  than  the  rest  of  the  arm.  In  children  who  are  young  and  of 
full  habit  an  eruption  of  roseola  sometimes  takes  place  on  the 
body  and  extremities,  having  a  papular  or  vesicular  appearance;  it 
occurs  about  the  ninth  or  tenth  day,  and  lasts  about  a  week. 
Vaccination  does  not  follow  the  same  course  in  all  cases,  the  vesicle 
being  developed  earlier  in  some  cases  than  in  others,  and  instances 
of  retarded  cow-pox  are  sometimes  met  with,  particularly  when  dry 
lymph  is  employed.  When  the  health  is  good,  children  should  be 
vaccinated  early,  but  when  they  are  delicate  it  should  be  postponed 
till  they  are  stronger.  "  It  is  enough  to  state  that  one  fourth  of 
the  deaths  of  small-pox  in  England  occurs  under  the  age  of  one  year. 


SPECIAL    ERUPTIVE    FEVERS.  99 

Of  20,590  deaths  from  small-pox  which  occurred  in  England  in  the 
six  years  1856-61,  5000  were  in  children  under  one  year  of  age."* 

There  is  no  exact  rule  to  go  by  as  to  the  time  of  taking  the  lymph, 
as  the  vesicle  varies  in  its  progress  to  perfection,  but  it  should  not 
be  taken  later  than  the  eighth  day  ;  sometimes  it  is  ripe  on  the  fifth 
or  sixth  day,  and  this  happens  when  the  arm  has  become  inflamed 
from  the  moment  of  inserting  the  vaccine. 

In  vaccinating  children  some  precautions  are  necessary  to  be 
observed.  No  child  who  is  out  of  health,  or  has  recently  had  scar- 
latina or  measles,  or  has  a  chronic  skin  eruption,  should  be  vac- 
cinated. If  boils  or  a  pustular  eruption  follow  vaccination  they 
will  demand  alterative  medicine,  tonics,  and  good  air.  These 
sequelae  are  occasionally  intractable,  and  the  ulceration  on  the  arm 
may  prove  most  rebellious  to  treatment.  I  have  often  witnessed 
the  inflammation  so  great  as  to  require  the  constant  application  of 
lead  lotion  under  oil-silk,  or  warm  fomentations.  Wasting  of  the 
deltoid,  and  paralysis  of  the  arm,  followed  vaccination  in  a  case  I 
saw  in  1873.  Sloughing  and  protracted  ulceration  of  the  shoulder 
ensued  in  the  case  of  a  child,  four  months  old,  brought  to  me  in 
June,  1880.    "A  case  of  fatal  pypemia  after  vaccination  "  is  recorded. f 

I  am  not  an  advocate  for  vaccinating  children  before  the  third 
month,  but  it  is  done  by  some  medical  men  as  early  as  the  sixth 
week. 

I^prefer  vaccination  from  arm  to  arm,  but  where  this  cannot  be 
done  the  vesicle  should  be  punctured  with  a  lancet,  and  the 
lymph  collected  in  an  open  capillary  tube,  drawn  up  by  capillary 
attraction.  One  end  of  the  tube  must  be  placed  within  the  vesicle, 
taking  care  to  avoid  contact  with  the  blood  or  pus.  When  it  is  full, 
the  ends  of  the  tube  are  to  be  closed  by  holding  them  in  the  flame 
of  a  spirit-lamp  or  candle. 

In  deciding  upon  the  spot  for  vaccination,  the  arm  just  below 
the  shoulder  is  usually  selected,  and  there  is  no  better,  for  the  part 
is  hidden  by  the  dress  of  women  whether  high  or  low  dresses  are 
fashionable.  If  there  should  be  a  growing  naevus,  or  other  ugly 
mark  on  the  skin,  it  may  be  selected  as  a  fitting  spot  for  the  opera- 
tion, and  in  many  cases  it  lessens  the  disfia^urement,  or  destroys  it 
altogether. 

Varicella  or  Chicken-pox. — This  disease   has  also  received    the 

*  Vaccination,  by  Dr.  Seaton,  Keynolds's  System  of  Medicine,  vol.  i,  p.  4S9. 
t  See  The  Lancet,  1860,  vol.  ii,  p.  263. 


100  DISEASES   OF   CHILDREN". 

name  of  swine-pox  or  bastard-pox.  It  is  botli  contagious  and  infec- 
tious, and  tlie  eruption  consists  of  small  vesicles  about  the  size  of  a 
hemp-seed,  which  never  become  pustular.  It  was  formerly  con- 
founded with  small-pox,  just  as  small -pox  and  measles  were  mixed 
np  together  and  not  recognized  as  distinct  diseases.  It  is  a  disease 
of  childhood  and  has  never  been  known  to  occur  a  second  time.  The 
period  of  incubation  lasts  from  ten  to  twelve  days  according  to  Dr. 
Murchison  and  Dr.  Squire.  Some  authorities  make  it  longer.* 
There  is  slight  febrile  disturbance,  and  the  disease  ends  without 
any  ill  consequences,  in  the  course  of  four  or  five  days.  The  child 
is  poorly  and  off  his  appetite;  there  is  lassitude  and  flying  pains 
about  the  limbs,  and  the  sleep  is  disturbed.  Small  red  pimples 
appear,  which  change  into  vesicles  containing  a  thin  transparent 
fluid,  or  slightly  turbid  serum.  On  the  third  day  they  mature 
and  burst,  and  dry  up  on  the  fifth  without  leaving  any  mark  as 
in  variola,  or  having  an  inflammatory  areola.  The  eruption 
comes  out  irregularly,  and  new  vesicles  may  be  seen  just  making 
their  ajDpearance  as  the  old  crop  are  fading  away.  It  is  first  observed 
on  the  body  and  back,  then  extends  to  the  face  and  scalp,  and  lastly 
is  seen  scattered  over  the  extremities.  When  the  vesicles  are  pricked 
they  collapse,  and  there  is  no  swelling  or  distinct  elevation  of  the 
skin.  Children  of  all  ages  are  liable  to  the  complaint,  but  it  is  not 
so  common  after  the  seventh  year.  It  cannot  be  communicated  by 
inoculation;  it  is  no  protection  against  small-pox,  and  vaccination 
has  no  power  to  prevent  the  disease. 

The  diagnosis  from  modified  small-pox  rests  on  the  fact  that  the 
eruption  of  varicella  is  most  marked  on  the  back,  the  face  often 
entirely  escaping,  and  that  owing  to  the  eruption  coming  out  in  an 
irregular  manner,  all  stages  may  be  met  with  at  the  same  place  on 
the  same  day,  whereas  in  small-pox  the  rash  is  either  all  papular, 
vesicular,  or  pustular. 

The  treatment  required  is  confinement  to  bed,  a  light  fluid  diet, 
and  a  saline  and  antimonial  aperient.  If  any  of  the  vesicles  are 
umbilicated,  and  likely  to  leave  a  scar  on  the  face,  they  may  be 
touched  with  collodion.  For  any  subsequent  weakness  that  re- 
mains during  convalescence,  a  little  quinine  or  the  syrup  of  the 
iodide  of  iron  will  be  found  necessary. 

*  See  Clin.  Trans.,  1878,  p.  240,  Observations  on  the  Period  of  Incubation  of  Scarlet 
Fever,  and  of  some  other  Diseases,  by  Charles  Murchison,  M.D. 


MORBILLI   OR   MEASLES.  101 

CHAPTER   X. 

MORBILLI    OR    MEASLES.* 

Varieties  of  Measles:  1.  MorhiUl  mitiores — 2.  Morhilli  (jraviores — 3.  Morbill  sinei 
catarrho — Symptoms  of  each  form — Character  of  the  eruption — Its  lingering  nature  in 
some  cases.  Mortality,  Causes,  and  Complications  :  Not  always  attributable  to 
unhealthy  localities — Frequency  of  bronchitis  and  pneumonia — Rapidity  ivith  which  the 
lung  becomes  hepatized  in  some  cases — Intestinal  irritation  and  diarrhosa — False  croup 
—Congestion  of  the  brain — Pharyngitis  and  aphthous  ulceration  of  the  mouth — Swelling 
of  the  cervical  glands — Case  in  illustration.  SEQUELiE  :  Oancrum  oris— Strumous 
ophthalmia  and  ulceration  of  the  cornea — Otorrhoea — Suppuration  of  the  cervical  glands 
— Chronic  diarrhoea — Phthisis.  Treatment  :  Importance  of  maintaining  a  warm 
temperature  and  good  ventilation  in  the  sick-room—  Utility  of  cupping  where  pulmonary 
engorgement  and  cerebral  congestion  are  present — Value  of  stimulants  in  the  typhoid 
stage  of  the  disease — Bidimia. 

Ileasles  is  a  more  prevalent,  but  a  less  dangerous  disease  than 
scarlet  fever,  and  the  greatest  proportion  of  children  that  fall  vic- 
tims to  it  are  under  the  age  of  five  years.  In  scarlet  fever  the  same 
rule  as  to  age  applies,  though  not  to  the  same  extent.  Although 
measles  is  essentially  a  disease  of  early  life,  it  may  occur  ahiiost  at 
any  age,  and  few  persons  at  one  time  or  another  escape  it,  whilst 
scarlet  fever  frequently  spares  people  altogether. 

The  period  of  incubation  is  much  longer  than  in  scarlatina,  and 
extends  from  ten  to  fourteen  days,  during  which  time  the  patient 
is  apparently  quite  well.  The  eruption  generally  appears  on  the 
fourth  day  of  the  fever.  In  my  own  famil}'-,  three  children,  who 
were  laid  up  with  it  at  the  same  time,  exhibited  a  short  febrile 
stage,  the  eruption  appearing  on  the  second  and  third  days  of  the 
fever,  and  cases  are  unquestionably  to  be  met  with  where  the 
catarrhal  symptoms  and  the  eruption  are  coincident. f 

*  "Measles  and  scarlet  fever  were  long  regarded  as  varieties  of  small-pox.  Measles 
was  first  distinguished  from  variola  by  Abu  Dschafar,  and  other  Arabian  physicians 
in  the  twelfth  century ;  but  measles  and  scarlet  fever  continued  to  be  looked  upon  as 
one  disease,  which  was  designated  '  morbilli.'  An  Italian  physician,  Philip  Ingrassias, 
of  Palermo,  in  the  middle  of  the  sixteenth  century,  first  described  scarlet  fever,  which 
he  called  '  rossalia,'  as  distinct  from  morbilli  or  measles." — Clinical  Lectures  on  Medi- 
cine, by  Dr.  Murchison.  A  Case  of  Rotheln,  or  German  Measles,  Lancet,  October 
29th,  1870,  page  595. 

f  Some  degree  of  confusion  and  even  error  are  apt  to  arise  in  calculating  the  dura- 
tion of  the  incubation  period,  some  authorities  reckoning  from  the  time  the  poison  is 
received  into  the  system,  and  the  first  appearance  of  symptoms,  whilst  others  calculate 
from  the  same  period,  till  the  eruption  shows  itself.  If  the  former  metliod  of  calculation 
is  adopted  it  will  reduce  the  incubation  period  to  ten   or  eleven  days.     See  Clin. 


102  DISEASES   OF   CHILDEEN". 

Three  varieties  of  measles  are  described  : 

1 .  Morhilli  mitiores. 

2.  Morbilli  graviores. 

3.  llorbilli  sine  catarrho. 

1.  llorbilli. — The  disease  sets  in  with  symptoms  resembling  the 
approach  of  a  severe  cold,  or  with  a  convulsive  seizure.  These  are 
pallor,  loss  of  appetite,  and  shivering ;  tlie  child  is  languid  and 
heavy,  and  lolls  where  it  can ;  headache,  drowsiness,  and  restless 
sleep,  with  wandering  and  screaming  at  night,  are  noticeable  warn- 
ings. These  symptoms  are  so  severe  in  some  children  that  it  is 
difficult  to  prevent  them  from  falling  out  of  bed.  About  the  third, 
or  more  frequently  the  fourth  day  after  these  premonitory  signs, 
the  eruption  appears.  At  first  it  is  not  unlike  fleabites,  and  may 
be  seen  on  the  forehead,  face,  thorax,  and  neck ;  in  one  case  under 
my  care  the  eruption  in  the  first  instance  seized  the  left  cheek  and 
neck,  and  twelve  hours  elapsed  before  the  eruption  appeared  on  any 
other  part  of  the  body ;  there  is  scarcelj^  any  on  the  arras  and  legs 
at  the  beginning,  but  in  the  coarse  of  twenty-four  hours  it  extends 
to  the  trunk  and  extremities,  and  may  be  noticed  on  the  back  of 
the  hands,  the  papules  being  darker,  smaller,  and  less  coherent. 
The  eyes  are  suft'used  and  watery,  and  the  conjunctivae  injected 
in  most  cases  ;  but  this  is  not  necessarily  so,  and  the  eyes  in  the 
worst  forms  may  have  a  dull  look  and  be  free  from  irritation ;  or 
the  lids  may  stick  together,  and  the  eyes  remain  closed  during  the 
activity  of  the  eruptive  stage.  The  mucous  membrane  of  the  nose 
and  fauces  is  congested,  and  there  is  frequent  sneezing  ;  the  cervical 
glands  are  felt  to  be  enlarged.  The  skin  is  hot,  and  the  tempera- 
ture may  run  up  to  104°  or  105°,  but  in  ordinary  cases  it  will 
rarely  be  found  to  exceed  102° ;  the  pulse  may  range  from  140  to 
160,  while  the  respiration  is  hurried  and  short.  The  bowels  ar© 
generally  costive,  though  there  may  be  diarrhoea,  and  the  urine  is 
turbid  and  contains  urates ;  the  tongue  is  covered  with  a  thick 
creamy  fur,  which  shows  points  of  redness  as  it  is  removed,  and 
the  whole  may  become  red  and  moist  by  the  eighth  or  tenth  day 
from  the  commencement  of  the  symptoms.  Pharyngitis,  pain  in 
swallowing,  thirst,  and  loss  of  voice  are  frequently  present,  and 
the  irritation  extending  into  the  lungs  causes  loss  of  sleep  and 


Trans.,  1878,  p.  238,  Observations  on  the  Period  of  Incubation  of  Scarlet  Fever,  and  of 
some  other  Diseases,  by  Charles  Murciiison,  M.D. 


MORBILLI   OR   MEASLES.  103 

restlessness.*  Remissions  and  exacerbations  are  comnaon,  as  in 
some  other  diseases  of  children.  Vomiting  is  occasionally  present 
at  the  commencement  of  the  disease,  but  it  is  far  less  frequent  than 
in  scarlet  fever,  and  is  not  so  generally  confined  to  the  early  stages. 
In  one  case,  however,  a  child  fourteen  months  old  vomited  thirty 
times  a  day,  and  before  the  eruption  appeared  I  dreaded  some 
cerebral  affection.  "Vomiting  occurred  during  the  first  stage, 
sometimes  almost  as  late  as  the  eruptive  period,  in  thirteen,  and 
was  absent  in  twenty-three  cases,  of  which  I  have  preserved 
records."f  The  little  patients  may  bring  up  bile  from  the  violence 
of  the  retching,  and  epistaxis  from  the  fulness  of  the  nasal  vessels 
is  not  unfrequently  met  with.  There  may  be  no  thoracic  compli- 
cation in  the  shape  of  cough  or  bronchitis  for  the  first  two  or  three 
daj's  of  the  eruption,  but  when  it  becomes  more  marked  and  de- 
veloped, and  is  raised  above  the  skin  in  blotches,  the  cough,  is  in- 
cessant and  irritating,  and  both  small  and  large  crepitation  are 
heard  throughout  the  chest.  I  have  noticed  the  upper  lobes  of 
both  lungs  frequently  attacked,  and  where  the  lower  w^ere  not  the 
first  to  show  signs  of  mischief,  and  that,  too,  in  cases  which  were 
not  tuberculous.  This  is  owing  to  the  extension  of  the  inflamma- 
tion down  the  larynx  and  trachea  to  the  bronchi.  When  the 
eruption  is  at  its  height,  and  the  bowels  are  free,  the  pulse  usually 
begins  to  fall  in  frequency,  and  the  temperature  declines,  but  the 
symptoms  do  not  generally  decrease  on  the  appearance  of  the 
eruption ;  they  often  increase,  and  the  breathing  becomes  acceler- 
ated and  embarrassed.  On  the  seventh  day  of  the  fever  the  erup- 
tion begins  to  fade,  and  by  the  tenth  day  the  child  may  be  down- 
stairs and  well,  having  scarcely  any  cough,  or  in  any  way  com- 
plaining. In  some  cases  there  is  only  occasional  loose  cough, 
without  any  physical  signs.  The  eruption,  too,  is  variable.  On 
the  morning  of  the  third  day  of  the  fever  it  may  be  copious  on 
the  face,  and  the  papulae  may  be  distinct  and  elevated  above  the 

*  A  delicate  boy,  aged  six  years,  came  under  my  care  in  March,  1877,  and  on  the 
fourth  day  of  the  fever  the  temperature  was  104.8°,  pulse  176,  respirations  28 ;  and  on 
the  seventh  day,  when  the  eruption  could  scarcely  be  defined,  the  temperature  reached 
105°,  pulse  200  running,  respirations  60  ;  there  were  extensive  r41es  through  the  front 
and  back  of  tlie  chest,  yet  the  urine  was  copious,  clear,  acid,  specific  gravity  1022,  and 
at  no  time  of  the  illness  did  it  throw  down  the  slightest  deposit,  or  deviate  from 
health.  As  an  instance  of  rapid  recovery  and  convalescence,  this  little  bo}^,  who  was 
near  death  on  the  28th  of  March,  and  in  a  critical  state  for  a  week  after,  was  running 
about  the  wai-d  with  scarcely  any  trace  of  catarrh  on  the  11th  of  April. 

t  On  Diseases  of  Children,  by  Lewis  Smith,  M  D.,  Philadelphia,  1869,  p.  461. 


104  DISEASES    OF    CPIILDREN. 

surface ;  by  the  evening  the  eruption  may  run  together,  and  as- 
sume a  large  vermilion  patch  on  the  cheek.  The  constitutional 
symptoms  run  high,  with  considerable  fever,  thirst,  and  w^andering  ; 
next  day  the  eruption  may  assume  a  more  purple  hue,  to  be  again 
followed  by  increasing  brightness  of  color.  Sometimes  it  is  con- 
fluent, resembling  scarlet  fever,  and  the  spots  are  dark  and  purplish 
from  rupture  of  the  capillaries,  and  remain  for  a  length  of  time, 
and  do  not  disappear  on  pressure.  Sometimes  the  rash  begins  to 
fade  as  early  as  the  fifth  or  sixth  day,  and  from  above  downwards 
in  the  order  in  which  it  has  first  appeared.  During  the  next  two 
or  three  days  the  cuticle  desquamates  in  furfuraceous  scales. 
About  this  time  diarrhoea  is  not  uncommon,  and  if  the  weather 
is  cold  and  great  precautions  are  not  observed,  capillary  bronchitis 
or  pneumonia  may  supervene.  If  on  the  seventh  day  of  the  fever 
there  is  an  increase  of  temperature,  and  the  pulse  and  respiration 
are  also  more  frequent,  we  may  reasonably  take  alarm,  because  the 
symptoms  have  become  aggravated  at. a  time  when  they  ought  to 
be  better.  In  such  cases  I  have  known  the  eruption  copious  and 
dusky,  with  the  features  swelled,  and  the  lips  dry  ;  in  a  recent 
case  under  my  care  there  was  albumen  in  the  urine  from  renal 
congestion,  wandering  at  night,  and  diftused  bronchitis. 

2.  MorbiUi  Graviores — Malignant  Measles. — The  symptoms  here 
are  more  severe  from  the  first ;  the  eruption  comes  out  irregularly, 
lasts  longer,  and  has  a  dark-claret  hue,  which  has  received  the 
name  of  black  measles.  It  is  slightly  raised  above  the  skin,  and 
has  the  appearance  of  petechi?e.  Some  authorities  do  not  consider 
this  a  distinct  species,  holding  that  the  darker  color  of  the  eruption 
is  due  to  imperfect  decarbonization  of  the  blood  from  pulmonary 
complication.  The  disease  beginning  as  morbilli  mitiores  may  pass 
into  this  grave  variety.  The  constitutional  symptoms  are  of  a 
typhoid  character,  the  pulse  is  frequent  and  small,  the  aspect  heavy 
and  bloated ;  the  tongue  is  dry  and  glazed  in  the  centre,  and  sordes 
collect  on  the  teeth  ;  the  motions  are  dark  and  putrid,  or  there  is 
severe  diarrhoea.  The  lungs  are  early  involved  in  capillary  bron- 
chitis or  pneumonia,  and  death  takes  place  in  many  instances  by 
asphyxia  or  coma.  There  is  dry  and  constant  cough,  and  the  child 
is  drowsy  and  indifierent.  Kfiles  are  heard  over  the  posterior  sur- 
face of  the  lungs,  and  air  enters  them  imperfectly.  I  have  known 
them  so  loud,  and  the  mucus  so  great  in  the  tubes,  as  to  give  rise 
to  physical  signs  bearing  a  close  resemblance  to  the  gurgling  of  a 


MOEBILLI   OR   MEASLES.  105 

cavity,  and  yet  in  a  week  after  the  whole  lung  has  been  resonant, 
while  scarcely  a  trace  of  bronchial  irritation  remains.  The  blood 
in  these  cases  is  dark  and  fluid,  and  the  tibriu  and  solid  parts  are 
deficient. 

3.  31orUlli  sine  Catarrlio. — This  is  by  some  regarded  as  merely  a 
mild  form  of  measles  without  the  occurrence  of  pulmonary  symp- 
toms; just  as  there  are  also  cases  in  which  the  eruption  fails  to 
come  out,  and  which,  with  all  the  other  symptoms  marked,  must 
be  classed  as  irregular  forms  of  measles.  The  fact  is,  however, 
many  cases  of  so-called  morbilli  sine  catarrho  are  really  cases  of 
rotheln,  or  nothing  more  than  varieties  of  erythema. 

The  mortality  of  measles  is  estimated  at  1.15  per  cent.,  but  the 
fluctuation  is  considerable  from  year  to  year.  It  is  essentially  a 
disease  of  early  life,  for  it  seldom  recurs,  and,  unlike  scarlet  fever, 
the  deaths  appear  to  be  greatest  between  one  aud  two  years  of  age. 
After  the  age  of  five  years  the  mortality  undergoes  great  diminu- 
tion. The  returns  of  the  Registrar-General  give  the  greatest 
number  of  deaths  before  the  completion  of  the  first  year ;  the  ab- 
solute mortality  is  greatest  among  male  children,  but  as  more 
boys  are  born  than  girls  the  proportional  death-rate  is  almost 
equal  in  both  sexes. 

CoAises. — The  disease  is  due  to  a  specific  poison,  and  it  may  be 
inoculated  by  the  blood  of  a  person  sufl^'ering  from  it,  or  the  secre- 
tion from  the  nose  and  air-passages.*  The  poison  is  more  powerful 
in  some  epidemics  than  in  others,  which  is  perhaps  due  to  atmos- 
pheric changes  ;  those  in  the  winter  months  are  proverbially  more 
severe  than  those  in  the  summer  mouths,  from  the  liability  to  more 
pulmonary  mischief.  The  cause  of  death  among  the  poor  is  in 
many  instances  pneumonia,  brought  on  by  want  and  exposure,  and 
inattention  to  temperature.  An  epidemic  does  not  always  seize 
upon  unhealthy  localities  where  dirt  and  destitution  abound,  or 
where  the  water-supply  is  deficient,  but  where  unrestrained  inter- 
course is  permitted  to  take  place  between  healthy  and  diseased 
children,  t 

*  Drs.  Braidwood  and  Yacher,  of  Birkenliead,  have  found  that  glycerin  bj-eathed 
on  by  a  patient  sufl'ering  from  measles  during  any  of  the  eruptive  days,  exhibited 
numerous  spherical  sparkling  bodies,  like  those  found  in  vaccine,  but  larger,  and 
others  elongated,  with  sharp  cut  ends  sparkling  and  colorless.  Such  particles  were 
not  found  in  glycerin  breathed  on  by  healthy  children,  nor  even  by  those  suffering 
from  scarlatina  or  typhus.     Trans.  Path.  Soc,  vol.  xxis,  p.  422. 

t  Outbreak  of  Measles,  Brit.  Med.  Journal,  Dec  1st,  1SG7,  p.  574. 


106  DISEASES    OF    CHILDREN. 

Of  the  complications  of  measles,  the  chief  are  bronchitis  and 
pneumonia,  and  these  most  frequently  commence  in  the  iirst  stage 
of  the  disease  when  the  eruption  is  at  its  height ;  or  when  the 
patient  has  sufiered  exposure  to  cold;  or  in  its  decline,  even  when 
the  most  assiduous  precautions  have  been  followed.  When  it  does 
arise  during  the  first  four  or  live  days  of  the  fever,  the  rash  often 
disappears,  and  the  pulmonary  symptoms  proceed  to  a  fatal  termi- 
nation. The  lung  speedily  runs  into  hepatization,  and  there  may 
be  scarcel}^  any  cough  to  direct  our  attention  to  it.  Wherever 
there  is  any  thoracic  mischief  the  chest  should  be  examined  at 
each  visit,  for  the  slight  bronchitis  which  almost  invariably  ac- 
companies measles  may  creep  down  into  the  air-passages,  and  ex- 
tend to  the  smaller  bronchial  tubes  and  the  vesicular  tissue  of  the 
lungs.  The  occasional  absence  of  cough  and  dyspnoea  should  not 
mislead  us,  when  we  remember  how  nmch  the  thoracic  organs 
may  be  involved  with  little  disturbance  of  their  functions.  But 
broncho-pneumonia  implicating  the  minute  structure  of  the  lungs 
will  soon  cause  acceleration  of  the  pulse,  and  produce  some  lividity 
of  the  features.  When  these  s^-mptoms  are  present  it  would  be 
inexcusable  to  overlook  the  physical  examination  of  the  chest. 

Another  complication  of  measles  during  its  progress  is  an  attack 
of  colitis,  in  which  the  motions  contain  mucus  and  blood,  accom- 
panied hy  pain  and  drawing  up  of  the  extremities.  The  solitary 
glands  are  inflamed  and  tumefied,  a  condition  which  may  run  on 
to  superficial  or  deepseated  ulceration,  and  the  child  may  perish 
from  diarrhoea  and  exhaustion.  If  it  occurs  after  the  eruptive 
stage  in  the  decline  of  the  complaint,  it  is  more  difficult  to  arrest, 
and  may  cause  death  after  some  weeks.  Thus  the  same  tendency 
to  irritation  of  the  pulmonary  mucous  membrane  is  apt  to  extend 
itself  to  the  intestinal  canal,  and  if,  from  constitutional  weakness, 
the  child's  strength  is  greatly  reduced  by  a  slow  and  imperfect  re- 
covery, then  phthisis  may  supervene  after  many  weeks  or  months. 

Croup  is  another  disease  which  occurs  as  a  complication  of 
measles.  A  case  is  recorded  b}^  Mr.  Royes  Bell,  of  a  boy,  seven 
years  of  age,  in  which  there  occurred  on  the  second  day  of  erup- 
tion a  cronpy  cough.  The  paroxysms  of  suffocation  became  so 
frequent  that  tracheotomy  was  performed,  but  the  child  died  of 
ulceration  of  the  trachea  fifteen  days  after.*  From  my  own  obser- 
vation I  should  say  that  inflammatory  croup  or  catarrhal  laryngitis 

*  Case  of  Measles  complicated  with  Croup,  the  Lancet,  vol.  i,  1879,  p.  295. 


MORBILLI   OR    MEASLES.  107 

was  not  uncommon.  It  is  characterized  by  soreness  of  the  larynx, 
and  a  loud,  shrill,  ringing  cough.  The  child  may  cough  up  a  little 
thin  phlegm,  but  no  false  membrane  is  ever  formed  as  in  membra- 
nous laryrigitis.  The  aspect  is  never  so  distressed  or  anxious,  nor 
is  the  voice  so  subdued,  or  the  cough  so  hoarse.  If  diphtheria  is 
epidemic  when  measles  prevails  it  is  a  frequent  complication,  and 
even  without  this  complication  the  mucous  membrane  of  the  mouth 
and  pharynx  sometimes  takes  on  an  aphthous  and  ulcerated  con- 
dition about  the  eighth  day,  when  the  decline  of  measles  is  ordi- 
narily looked  for.* 

*  On  tlie  17th  of  April,  1877,  at  10  o'clock  a.m.,  I  saw,  with  Dr.  Cleveland,  of  Maida 
Vale,  a  male  child,  eighteen  months  old,  who,  on  the  seventh  day  of  measles,  was  seized 
Avitli  swelling  of  the  cervical  glands  on  both  sides  so  as  to  obliterate  the  ramus  of  the 
jaw.  I  saw  him  on  the  eighth  day,  when  the  temperature  was  102.4°,  the  pulse  128, 
respiration  tranquil ;  the  mucous  membrane  of  the  cheeks  and  lips,  the  sides  of  the 
tongue,  pharynx,  and  tonsils,  were  covered  with  a  yellowish  fibrinous  exudation,  which 
was  firmly  adherent  to  the  mucous  membrane  in  some  places,  but  easily  separated  in 
others.  The  child  could  swallow  and  speak  distinctly,  but  there  was  irritation  in  Oie 
larynx  and  a  little  mucus  in  the  upper  bronchial  tubes  as  revealed  by  auscultation.  A 
spray  of  carbolic  acid  was  used  (1  in  50)  with  the  effect  of  dislodging  a  considerable 
quantity  of  mucus  from  the  air-tubes,  which  gave  great  relief  (see  Chapter  XI,  "On 
Scarlet  Fever").  At  9  p.m.  he  was  intelligent  and  clear,  the  glands  were  less  swollen, 
the  throat  was  less  oppressed,  and  the  breathing  easier,  but  the  temperature  was  104.8°  ; 
the  pulse  small  and  running  180,  respirations  50;  the  face  was  flushed,  the  tongue  dry- 
ish; he  was  disposed  to  sleep,  and  could  swallow  well. 

On  the  18th,  10  a.m.,  the  temperature  was  104°.  He  had  been  restless  and  uneasy 
all  night;  there  was  much  discharge  from  the  mouth  and  nostrils. 

On  the  19th,  10  a.m.,  temperature  102°.  His  general  appearance  was  better,  and 
his  bowels  had  acted  very  freely  from  the  mixture  of  chlorate  of  potash,  quinine,  and 
dilute  hydrochloric  acid  ordered  on  the  preceding  day.  At  3.15  p.m.  temperature  102°  ; 
was  cheerful  and  observant,  refused  beef  tea,  but  took  milk  without  much  forcing.  10 
p.m.,  temperature  103°,  pulse  slightly  better,  discharge  from  mouth  and  nose  less;  the 
spray  had  been  used  twice;  glands  on  right' side  of  face  .less  swollen. 

20th,  10  A.M.,  temperature  100.8°.  He  appeared  wonderfully  better,  sitting  up  in 
bed  and  looking  bright,  but  in  the  evening  he  was  more  feverish,  and  the  temperature 
was  101.2°. 

21st,  10  A.M.,  temperature  101°.  Less  cheerful,  being  listless  and  indifferent ;  there 
was  great  difficulty  in  getting  him  to  take  nourishment.  Brandy  and  milk  given  every 
three  hours.  The  swelling  and  inflammation  in  the  throat  had  increased,  but  the  dis- 
charge was  less,  pulse  running  and  rather  feeble.  10  p.m.,  temperature  103°,  pulse 
still  feeble  and  quiet;  seemed  sluggish  when  left  alone  and  violently  irritable  when 
disturbed  to  have  food  given  him  ;  some  soreness  in  swallowing,  but  took  milk  without 
much  pressing. 

22d,  temperature  101.8°.  Looked  brighter,  and  glanced  about  quickly;  had  taken 
a  pint  of  milk  during  the  night,  and  thirty  drops  of  brandy  every  three  hours;  the 
pulse  was  feeble  and  he  was  much  inclined  for  sleep.  At  another  consultation  (3  p.m.) 
the  temperatui-e  had  reached  103.3°,  pulse  128,  feeble,  respiration  quiet,  the  tongue  was 


108  DISEASES   OF   CHILDEEN. 

In  tliree  or  four  instances  in  my  own  experience,  congestion  of 
the  brain  and  effusion  into  the  ventricles  and  base  of  the  brain 
carried  the  children  off. 

Among  the  sequelce  are  cancrum  oris,  and  a  severe  and  trouble- 
some form  of  strumous  ophthalmia,  leading  in  many  cases  to 
ulceration  of  the  cornese  and  permanent  damage  of  the  organs  of 
vision.  Otorrhoea  is  another  common  affection,  so  is  suppuration 
of  the  cervical  glands ;  chronic  diarrhoea,  phthisis,  croup  and  en- 
largement of  the  mesenteric  glands  are  also  among  the  consequences 
of  the  disease.  When  whooping-cough  follows,  it  has  probably 
been  contracted  beforehand. 

Except  in  the  malignant  form,  measles  may  be  considered  a 
favorable  disease  if  the  febrile  symptoms  are  moderate,  and  the 

partially  covered  with  a  creamy  exudation  at  the  sides,  inside  of  cheeks  and  lips,  and 
there  was  a  small,  irregular,  dirty  ulcer  below  the  inferior  incisor  teeth ;  the  pharynx 
was  red  and  swollen,  and  an  attempt  at  examination  dislodged  from  the  air-passages  a 
good  deal  of  muco-purulent  secretion ;  the  nasal  passages  were  also  discharging  a 
watery,  glairy  secretion,  but  in  no  way  offensive;  the  urine  was  clear  and  non-albumi- 
nous. As  there  had  been  some  purging  from  the  chlorate  of  potash  and  quinine  mix- 
ture, Dr.  Cleveland  gave  five  minims  of  tincture  of  the  perchloride  of  iron  in  a  little 
syrup  of  orange-peel  every  four  hours ;  a  poultice  was  applied  to  the  throat. 

23d,  10  A.M.,  temperature  101.3°.  The  mouth  was  less  swollen;  he  swallowed  well 
and  drank  milk  freely.  At  10  p.m.  the  temperature  rose  to  103.4°,  the  glands  and 
throat  were  more  swollen,  and  he  M'as  restless  and  averse  to  nourishment. 

24th,  10  A.M.,  temperature  101.4°,  pulse  136,  respirations  40.  The  lungs  were  clear 
and  resonant  throughout,  and  there  was  neither  difficulty  in  swallowing  nor  embarrass- 
ment in  respiration ;  a  large  white  aphthous  patch  covered  the  hollow  of  the  hard 
palate  and  the  tongue ;  the  neck  was  much  swollen,  but  no  sign  of  suppuration.  The 
iron  and  chlorate  of  potash  mixture  was  resumed.  10  p.m.,  temperature  102°.  General 
appearance  dull  and  feeble;  would  take  nothing  but  milk  with  a  little  brandy  in  it. 

25th,  10  a.m.,  temperature  100.8°.  Throat  much  less  swollen,  and  general  appear- 
ance brighter;  was  interested  in  his  playthings,  and  talked  a  little;  discharge  from 
nose  less,  but  slimy  saliva  was  discharged  from  the  mouth.  Had  taken  a  quart  of  milk 
and  two  eggs,  and  occasionally  half  a  teaspoonful  of  brandy  in  twenty-four  hours. 

27th,  10  A.M.,  temperature  99.8°.  Nasal  discharge  had  ceased  ;  the  mouth  was  much 
cleaner,  and  the  secretion  diminished  ;  cervical  glands  much  reduced  in  size,  but  the 
pliaryngeal  redness  continued.     10  p.m.,  temperature  101°  ;  pulse  good  ;  sleeps  well. 

29th,  10  A.M.,  temperature  99.4°.  Had  wonderfully  improved,  and  sat  up  for  a  short 
time  near  the  fire  ;  glands  again  smaller  in  size,  and  no  difficulty  whatever  in  swallow- 
ing. Has  complained  for  two  days  of  tenderness  about  the  wrist  of  right  arm,  and  to- 
day both  arms  seem  affected  with  rheumatism. 

May  2d.  Had  had  pains  in  the  parts  last  alluded  to,  but  he  ran  about  the  room,  and 
was  removed  to  his  mother's  home,  some  two  miles  distant;  temperature  99°. 

May  12th.  No  complaint  of  pain  now;  the  ulcer  on  the  inside  of  the  lower  lip  had 
not  liealed,  but  the  glands  of  the  neck  were  natural,  and  he  was  in  every  respect  con- 
valescent. 


MORBILLI   OR   :MEASLES.  109 

eruption  comes  oat  well.  ]S"ot\Yithstanding  the  activity  of  the 
eruption,  it  is  to  be  viewed  with  apprehension  if  the  skin  is  hot 
and  dry,  and  the  respiration  hurried.  If  the  fever  increases  after 
the  appearance  of  the  rash,  and  the  pulse  becomes  quick  and  small, 
the  patient's  condition  is  alarming  ;  and  if  pneumonia  or  whooping- 
cough,  or  constant  diarrhcea  be  present,  the  danger  is  proportion- 
ately greater. 

Treatment. — The  temperature  of  the  room  should  not  be  less 
than  70°,  and  all  draughts  should  be  carefully  excluded.  In  mild 
cases  it  is  only  necessary  to  confine  the  patient  to  bed,  and  to 
maintain  warmth  and  a  gentle  action  of  the  bowels.  For  the  first 
three  or  four  days  the  diet  should  consist  of  gruel,  milk  and  water, 
thin  beef  tea,  or  chicken  broth.  Barley-water  flavored  with  lemon, 
linseed  tea,  and  the  inhalation  of  steam  will  be  grateful  to  the 
sore  and  inflamed  mucous  membrane.  If  the  febrile  symptoms 
are  considerable,  a  diaphoretic  mixture*  with  a  little  antimonial 
wine  every  four  hours,  or  a  saline  aperient,t  will  be  necessary  to 
encourage  the  action  of  the  skin  and  bowels.  Sometimes  a  warm 
bath,  if  the  skin  is  dry,  to  promote  perspiration,  will  be  found 
serviceable.  When  symptoms  of  exhaustion  are  threatening,  the 
carbonate  of  ammonia,  with  a  little  spirit  of  nitrous  ether,  may 
be  given,  and  alcoholic  stimulants,  if  they  seem  to  be  demanded, 
such  as  brandy  or  sherry  beaten  up  with  Qgg;  and  raw-beef  juice 
has  proved  useful  in  cases  that  at  one  period  of  the  illness  ap- 
peared hopeless.  If  the  cough  is  very  troublesome,  and  the  patient 
can  obtain  no  rest  at  night,  a  little  ipecacuanha  wine  with  morphia, 
or  the  compound  tincture  of  camphor  may  be  prescribed  when  the 
lungs  are  not  overloaded  with  mucus  (Form.  77).  Hydrate  of 
chloral,  with  syrup  of  tolu,  or  these  combined  with,  bromide  of 

*  Formula  7 : 

R.  Liquor,  amm.  acet.,      ........     gj 

Vin.  antim.,  .........     "^xl 

Syr.  tolutani, giij 

Aquam  ad ^^iv. — M. 

A  tablespocnful  every  four  hours.     For  a  child  five  or  six  years  old. 
f  Formula  8 : 

R.  Magnes.  sulph.,  .         .         .         .         .         .         .         .         .     gr.  xl 

Potass,  nitrat.,     .........     ^ss. 

Syr.  limonum,  vel  syr.  tolut.,       ......     ^iij 

Aquam  ad  .........     3iv. — M. 

A  tablespoonful  every  four  hours.     For  a  child  five  or  six  years  old. 


110  DISEASES    OP    CHILDREN. 

potassium,  will  allay  excitability  and  promote  sleep,  whilst  a  warm 
batli  is  soothing  and  hastens  the  process  of  desquamation. 

When  the  pulmonary  symptoms  are  severe,  and  there  is  drowsi- 
ness, blood  should  not  be  taken  from  the  arm,  but  cupping  between 
the  scapulae  may  be  resorted  to  if  the  pulse  is  small,  jBrm,  and 
hard,  and  the  rash  well  out.  After  this  the  air  will  enter  the 
lungs  more  freely,  and  the  duskiness  of  the  eruption  will  be  ex- 
changed for  a  more  general  redness.  In  the  malignant  form  of 
the  disease,  where  there  is  a  typhoid  condition,  the  strength  must 
be  supported  from  the  first,  and  eggs,  beef  tea,  milk,  coffee,  etc., 
must  be  regularly  given.  Brandy  or  wine  should  be  mixed  with 
an  egg  or  milk,  and  given,  notwithstanding  any  delirium  that  may 
be  present.  If  the  breathing  is  hurried,  or  there  is  dulness  or 
crepitation  in  the  lungs,  and  especially  if  there  is  any  difficulty  in 
expectoration,  carbonate  of  ammonia,  spirit  of  chloroform,  and 
senega  will  be  necessary  (Form.  69,  70).  If  the  eruption  is  dusky, 
or  disappears  too  suddenly,  and  there  is  any  oppression  in  breath- 
ing, mustard  poultices  should  be'  applied  to  the  chest,  the  feet 
plunged  into  warm  water,  and  wine  and  difi:usible  stimulants  freely 
given. 

When  the  child  begins  to  recover,  and  during  convalescence,  it 
cannot  be  too  much  insisted  on  that  all  chance  of  cold  should  be 
carefully  avoided,  as  neglect  of  this  rule  may,  by  weakening  the 
general  health,  invite  some  of  the  troublesome  sequelse  we  have 
alluded  to,  and  among  them  tuberculosis  ;  for  measles  seems  to 
have  the  power  of  especially  rousing  into  activity  the  various 
forms  of  scrofulous  disease.  Warm  clothing  and  flannel  worn 
next  the  skin  are  most  important,  and  sea-bathing  and  cold  spong- 
ing are  very  valuable,  if  used  in  proportion  to  the  strength  and 
constitution  of  the  child. 

When  measles  has  been  severe,  and  has  reduced  the  general 
strength  by  causing  some  degree  of  subacute  pneumonia,  or  chronic 
intestinal  disorder,  it  is  sometimes  followed  by  a  voracious  appe- 
tite, and  a  sensation  of  hunger  approaching  to  bulimia.  This  is 
also  noticeable  as  a  sequel  to  some  other  diseases  of  children  where 
digestion  is  imperfectly  performed,  and  the  absorption  of  the  chyle 
does  not  ensue  owing  to  disease  of  the  mesenteric  glands.  If,  be- 
cause of  this  insatiable  appetite,  food  is  injudiciously  given,  the 
digestive  organs  are  never  rested,  but  grow  weaker  and  weaker, 
whilst  the  body  slowly  wastes.     In  these  cases  the  complexion  is 


ROTHELN,   OR   GERMAN   MEASLES.  Ill 

wan  and  pale,  and  nothing  does  any  real  good.  The  tongue  is 
commonly  covered  with  a  light  fur  in  the  centre,  and  the  papillae 
are  prominent,  the  epithelium  peels  oft'  in  places,  and  it  presents  a 
sore  and  ragged  appearance.  These  children  swallow  their  food 
as  soon  as  it  is  in  their  mouths,  and  thus  overtax  the  feeble  mu- 
cous membrane.  The  rational  treatment  consists  in  restraining 
the  child's  consumption  of  food,  and  giving  at  first  an  exclusively 
milk  diet,  and,  later  on,  beef  tea,  eggs,  etc.  Medicinally,  a  few 
'grains  of  chlorate  of  potash,  with  dilute  hydrochloric  acid,  will 
be  useful.*  Quinine,  steel  wine,  and,  above  all,  cod-liver  oil  will 
be  found  of  the  greatest  service  during  convalescence. 

ROTHELN,  OR   GERMAN   MEASLES    (RUBEOLA   NOTHA). 

Us'uaUy  a  mild  affection,  resembling  common  measles— Premonitory  fever  seldom  exceeds 
twenty-four  hours — Eruption  brighter  than  in  measles,  less  diffused  than  in  scarlatina 
— Cervical  glands  slightly  enlarged — Symptoms  and  treatment. 

JRotheln,  or  German  measles  (scarlatina  morhillosa — hybrid  mea- 
sles).i'\  is  reckoned  as  a  mild  aftection,  and  frequently  fails  to  come 
under  the  notice  of  the  great  bulk  of  the  profession.  It  is  still, 
however,  of  importance,  and  possesses  a  few  special  peculiarities 
with  which  we  ought  to  be  acquainted.  Formerly  some  observers 
regarded  the  disease  as  a  modification  of  measles  and  scarlatina. 
I  am  disposed  to  think  that  doubtful  cases  of  erythema  or  urti- 
caria are  sometimes  mistaken  for  measles  or  scarlatina ;  for  it  is 
certain  that  in  practice  we  encounter  cases  of  febrile  excitement 
in  young  children  attended  with  an  obscure  rash  which  it  is  im- 
possible to  classify  under  any  recognized  exanthem.    It  is  probable 

*  Formula  9 : 

R.  Potass,  chlorat., gr.  xx 

Acid,  hydrochl.  dil., rr^xl 

Syr.  hemidesmi, .     §S3. 

Aqiiam  ad ^iv. — M. 

A  tablespoonful  three  times  a  day.  For  a  child  five  years  old. 
t  It  is  clear  that  the  name  of  "  hybrid  measles  "  or  "  hybrid  scarlatina  "  is  both  ob- 
jectionable and  confusing,  because  it  is  calculated  to  lead  the  observer  to  suppose  that 
the  disease  is  a  modified  form  of  measles  or  scarlatina,  or  in  other  words  a  combina- 
tion of  the  two  disorders.  Copland  (Med.  Diet.,  p.  652)  speaks  of  rotlieln  under  the 
head  of  rose-rash,  and  terms  it  red-rash,  or  fiilse  measles.  The  leading  features 
appear  to  be  the  absence  of  catarrhal  symptoms,  the  slight  amount  of  fever,  and  the 
enlargement  of  the  cervical  glands. 


112  DISEASES    OF    CHILDREN. 

that  Vogel,*  under  the  title  of  rothehi,  describes  the  same  disease 
as  the  one  under  consideration,  though  he  says  the  duration  of 
the  eruption,  which  is  considered  the  most  characteristic  symp- 
tom, Lasts  only  one,  or  at  most  two  days,  whereas  Murchison  and 
Liveing  say  that  it  continues  four  days.  These  writers  both  speak 
of  the  occasional  presence  of  catarrh,  whilst  the  German  author 
notifies  its  uniform  absence.  But  probably  different  epidemics 
vary  a  little  in  their  symptoms,  as  we  find  is  the  case  with  com- 
mon measles. 

The  disease  presents  some  symptoms  allied  to,  but  many  unlike, 
the  common  form  of  measles.  The  eruption  is  said  to  partake  of 
the  character  both  of  measles  and  scarlatina,  yet  it  is  now  regarded 
as  specific  and  distinct  from  both.  The  swelling  of  the  throat 
and  tonsils,  and  the  white  coated  tongue,  followed  by  redness  and 
enlargement  of  the  papillee,  resembles  scarlatina  ;  while  the  ca- 
tarrh and  congestion  of  the  air-passages  liken  it  to  measles.  But 
it  is  less  severe  than  either  of  these  fevers. 

In  severe  cases  the  complaint  is  ushered  in  with  shivering  and 
febrile  disturbance,  headache,  pains  in  the  limbs,  sore  throat,  red- 
ness of  the  pharynx  and  tonsils,  and  in  some  instances  nausea,  and 
even  vomiting.  In  addition  to  these  sjmiptoms,  the  respiratory 
organs  are  sometimes  slightly  affected,  and  there  is  catarrh,  short 
cough,  sneezing,  and  coryza.  There  is  not  this  complete  set  of 
symptoms  in  all  cases,  but  some  are  usually  present.  The  remark- 
able feature  of  the  aft'ection  is,  that  the  premonitory  fever,  instead 
of  lasting  three  or  four  days  as  in  common  measles,  seldom  con- 

*  "  The  exanthema  differs  in  no  respect  from  that  of  morbilli ;  small  round  spots 
of  the  size  of  lentils  cover  the  entire  body,  occasioning,  in  most  instances,  a  consider- 
able amount  of  itching.  At  some  places  these  spots  stand  so  closely  together  that  they 
coalesce  and  form  irregular  figures.  They  also  rise  somewhat  above  the  level  of  the 
normal  integument,  and  tiie  finger,  in  lightly  passing  over  them,  perceives  an  unequal 
hare  ness.  The  eruption,  however,  differs  very  much  from  measles  in  respect  of  its  duration. 
It  completely  disappears  by  the  end  of  the  first,  or,  at  the  longest,  by  the  end  of  the 
second  day,  and  the  desquamation  tliat  succeeds  it  is  very  insignificant,  barely  notice- 
able. Tlie  same  is  true  of  the  catarrhal  symptoms.  Although,  along  with  an  in- 
tense erui)tion  of  the  exanthema  on  the  face,  the  eyelids  swell  up,  and  the  conjunc- 
tivae are  somewhat  injected,  still  bronchial  catarrh  is  uniformly  absent,  which,  in  mor- 
billi, on  the  contrary,  is  a  pathognomonic,  never-failing  symptom.  Scarcely  any  pre- 
cursory stage  wa.s  noticeable  in  most  of  onr  cases,  and  the  indistinct  febrile  plienomena 
disappeared  so  completely  after  tlie  first  day,  with  the  fading  of  the  exanthema  which 
soon  followed,  that  by  the  tliird  day  it  was  totall.v  im))ossible  to  keep  the  ciiildren  in 
bed,  and  they  quickly  recovered  without  the  first  sequelae." — Diseases  of  Children,  1874, 
p.  495. 


EOTHELN,    OR    GERMAN    MEASLES.  113 

tinues  more  than  twentj'-four  hours,  when  the  rash  makes  its 
appearance,  and  hence,  if  this  he  true,  we  have  a  means  of  diag- 
nosis which  is  distinct  and  valuable. 

The  eruption  first  ap[)ear3  on  the  thorax  and  arms,  but  often  on 
the  face  and  neck ;  it  is  characterized  hy  small,  red,  elevated 
patches,  or  distinct  and  minute  round  papules.  They  sometimes 
coalesce  and  run  together,  forming  large  and  irregular  patches, 
and  when  the  patches  unite,  the  body  becomes  universally  red, 
and  the  eruption  resembles  that  of  scarlet  fever,  being  brighter 
than  that  seen  in  measles.  When  the  rash  disappears  the  skin 
may  desquamate  in  branny  scales,  so  we  cannot  attach  much  im- 
portance to  desquamation  as  a  diagnostic  feature.  "The  eruption 
is  copious  in  a  direct  ratio  to  the  severity  of  the  general  sj-mp- 
toms.""  With  the  appearance  of  the  eruption  the  throat  affection 
is  apt  to  increase,  and  the  swelling  in  rare  instances  becomes  so 
great  that  the  patient  is  unahle  to  swallow.  The  cervical  glands, 
too,  become  inflamed  and  enlarged. f  "The  protracted  duration 
of  the  eruption  is  certainly  one  of  the  characteristics  of  the 
malady,  though  no  doubt  a  more  or  less  variable  one,  and  of  little 
or  no  value  as  a  means  of  early  diagnosis.  In  the  case  under  my 
care  in  the  hospital  the  eruption  lasted  from  five  to  seven  days,  a 
longer  time  than  is  usual  either  in  measles  or  scarlet  fever.":}:  It 
appears  to  me  that  not  much  reliance  can  he  placed  upon  the  dura- 
tion of  the  eruption,  or  to  the  extent  of  the  desquamation,  as  in 
one  case  of  ordinary  measles  under  my  care  in  April,  1877,  the  skin 
was  desquamating  at  the  end  of  a  month,  the  eruption  though 
faded  was  distinct  at  the  fourteenth  day,  and  after  washing,  it 
was  quite  bright  on  the  extremities,  neck,  and  shoulders. 

Another  very  important  feature  of  rotheln  is  that  it  never  pro- 
duces measles  or  scarlatina  in  others,  so  that,  from  this  point  of 
view,  it  is  entitled  to  be  regarded  as  a  distinct  and  independent 

*  Case  of  Rotheln  or  German  Measles,  by  Dr.Murchison,  Lancet,  Oct.  29th,  1870,  p.  595, 
t  In  the  cases  described  by  Dr.  Julius  Pollock,  the  cervical  glands  were  a  good  deal 
enlarged,  the  tonsils  swollen  and  red,  and  where  the  rash  faded  a  mottling  of  the  skin 
remained,  in  most  cases  for  several  days.  The  period  of  incubation  varied  from  6  to  8 
or  14  to  16  days. — Lancet,  May  12tli,  1877,  p.  681.  Dr.  Squire  gives  the  period  of  in- 
cubation from  14  to  21  days.  Mr.  Parker  Douglas  says  that  the  glands  beliind  the 
sterno-mastoid  were  afiected  in  his  cases,  that  coryza  is  not  invariable,  and  that  a  mot- 
tling of  the  skin  is  left  which  persists  for  a  few  days. — Lancet,  May  26th,  1877,  p.  784. 
X  On  Rotheln,  or  German  Measles,  by  R.  Liveing,  M.D.,  Lancet,  March  14th,  1874. 
See  also  Diagnosis  of  Skin  Diseases,  p.  44. 


114  DISEASES    OF    CHILDREN. 

disease.  It  has  a  tendency  to  propagate  itself,  and  epidemics  of  it 
have  been  recorded,  but  it  is  doubtful  whether  the  disease  is  so 
contagious  as  the  other  exanthemata.  It  affords,  moreover,  no 
protection  against  the  two  diseases  to  which  it  bears  a  close  resem- 
blance, for  some  children  who  have  suffered  from  it  previously, 
and  others  subsequently,  had  both  scarlatina  and  measles ;  and 
those  suffering  from  it  have  not,  in  a  single  instance,  communi- 
cated either  of  these  latter  diseases  to  others. 

The  disease,  though  highly  contagious,  appears  to  be  more  epi- 
demic than  measles  or  scarlatina,  and  is  a  milder  affection  than 
either.  One  attack  is  protective  against  a  recurrence  of  the 
disease,  but  not  against  a  subsequent  attack  of  common  measles. 

The  idea  has  been  started  that  rotheln  is  common  measles  modi- 
fied by  a  previous  attack,  but  the  fact  that  rotheln  frequently  pre- 
cedes measles  is  conclusive  against  this  view. 

Albuminuria  and  dropsy  are  rare  complications ;  these  dis- 
eases may  result  from  the  temporary  renal  congestion  of  ordinary 
measles,  but  their  absence  distinguishes  them  from  the  sequelse  of 
scarlatina. 

I  would  again  repeat  that  the  typQ  of  the  disease  varies  with  the 
particular  epidemic;  a  fact  which  is  too  apt  to  be  lost  sight  of; 
and  which  explains  the  slight  differences  in  the  descriptions  of 
authors. 

The  treatment  consists  in  confinement  to  bed,  a  febrifuge  mixture 
to  encourage  diaphoresis  (Form.  7, 12),  and,  if  catarrhal  symptoms 
arise,  demulcent  and  sedative  remedies  (Form.  65,  QQ^  74)  as  the 
case  may  appear  to  demand  them. 


SCAELET   FEVER   OR   SCAKLATIXA.  115 

CHAPTER   XL 

SCARLET  FEVER  OR  SCARLAimA.* 

Vakieties  of  the  Fever  and  theik  Classification  :  ] .  Scarlatina  simplex — 
The  premonitory  or  incubation  stage — 2.  The  stage  of  eruption— S.  The  stage  of  decline 
and  desquamation.  2.  Scarlatina  Anginosa  :  Character  of  the  throat  affection  and 
its  relation  to  the  eruptive  stage — Increased  severity  of  the  constitutional  symptoms — State 
of  the  tongue,  pulse  a7id  temperature — Alteration  in  the  cardiac  sounds.  3.  Scaklatina 
Maligna  :  State  of  throat  and  tonsils — Constitutional  symptoms  of  an  adynamic  type. 
4.  Scarlatina  sine  Eruptione  :  Absence  of  the  specific  eruption  and  mildness  of 
the  symptoms — Tendency  to  anasarca  and  dropsy.  Pathology:  Relation  to  enteric 
fever — Coexistence  of  the  two  diseases — Dr.  Klein's  researches  on  the  minute  anatomy 
of  scarlet  fever.  Causes  and  Consequences  :  Predisposing  and  exciting  causes — • 
Pathology  and  morbid  appearances — Mortality — Sequelce  of  scarlet  fever — Liability  to 
finasarca  and  acute  desquamative  nephritis — Congestive  or  uremic  headache.  Treat- 
ment AND  General  Management  of  the  different  varieties  :  Aconite  and 
its  mode  of  action — Liquor  ammonice — Sponging  the  body  in  high  temperature — De- 
lirium and  coma — Scarlatincd  dropsy — Effusion  into  the  serous  cavities — Treatment  of 
the  throat  affection — Preventive  measures. 

Scarlet  fever,  or  scarlatina,  may  be  defined  as  a  contagions  and 
infectious  fever,  attended  with  a  scarlet  rash  on  the  bodj,  and  with 
inflammation  of  the  throat  and  fauces.  Three  varieties  are 
described  : 

1.  Scarlatina  simjylex. 

2.  l:^carlatina  anginosa. 

3.  Scarlatina  maligna. 

Scarlatina  has  three  well-defined  stages :  1.  The  premonitory  or 
incubation  stage.  2.  The  stage  of  eruption.  3.  The  stage  of  de- 
cline and  desquamation. 

1.  TJie  incubation  stage  lasts  from  the  day  of  infection  till  the 
commencement  of  the  febrile  symptoms,  and  is  usually  short.  It 
may  extend  from  three  to  five,  or  even  eight  days.  In  some  in- 
stances the  period  may  continue  only  a  few  hours. f     There  is  no 

*  "  The  term  '  Scarlatina '  is  said  to  have  been  the  vernacular  name  for  the  disease 
on  the  shores  of  the  Levant,  and  was  first  adopted  in  a  medical  work  by  Prosper  Mar- 
tianus,  another  Italian  physician,  who,  about  the  middle  of  the  sixteenth  century,  also 
described  the  disease  as  distinct  from  morbilli.  Epidemics  of  scarlet  fever  were  first 
described  in  this  country  by  Sydenham  in  1676,  and  about  the  same  time  in  Scotland 
by  Sir  Eobert  Sibbald,  pliysician  to  Charles  II,  and  in  the  middle  of  last  century  by 
Fothergill  and  Huxham." — Clinical  Lectures  on  Medicine,  by  Dr.  Murchison,  Case  of 
Eotheln  or  German  Measles. — The  Lancet,  Oct.  29th,  1870,  p.  595. 

t  Of  75  cases  collected  by  Dr.  Murchison,  the  latent  period  was  less  than  twenty- 
four  hours  in  some,  and  in  none  did  it  exceed  six  days. — Clin.  Trans.,  1878,  p.  257. 


116  DISEASES    OF    CHILDREN. 

exact  rule  to  go  hx  as  to  the  duration  of  this  stage  :  one  child  will 
resist  infection  for  a  longer  period  than  another,  or  the  infection, 
■u'ill  be  slower  in  disturbing  the  constitution.  Some  children  are 
more  susceptible  than  others;  and  the  character  of  the  epidemic 
may  differ  in  severity.  A  child  may  be  feeling  out  of  sorts  for 
daj-s,  languid,  depressed,  and  "  off  his  appetite ,"  but  the  illness 
excites  no  apprehension  if  scarlet  fever  be  not  prevalent  at  the 
time.  "When  chilliness,  thirst,  quick  pulse,  and  increased  tempera- 
ture of  the  skin  succeed,  the  parents  become  anxious.  Diagnosis 
is  even  now  impossible,  but  if  there  is  nausea  or  vomiting,  and  the 
tonsils  and  fauces  are  inflamed  during  the  prevalence  of  an  epi- 
demic, we  can  scarcely  mistake  the  character  of  the  fever.  As 
the  case  progresses  the  breath  becomes  intensely  hot,  the  skin 
pungent  and  burning  ;  and,  to^^'ards  the  evening,  or  during  the 
night,  the  cerebral  functions  may  be  so  disturbed  as  to  lead  to 
convulsions  or  delirium.  At  this  stage  the  characteristic  eruption 
will  appear,  and  it  is  seldom  delayed  beyond  twenty-four  hours. 

2.  7he  eruptive  stage  is  marked  hy  small  red  points  upon  the 
face  and  neck,  which  extend  to  the  trunk  and  limbs,  especially  the 
inside  of  the  thighs,  and  the  flexures  of  the  joints.  In  the  course 
of  twelve,  or  at  most  twenty-four  hours,  the  eruption  assumes  a 
general  erythematous  appearance,  and  the  little  patient  becomes  as 
red  as  a  "  boiled  lobster."  The  rash,  however,  is  often  variable  in 
severity,  and  mixed  in  its  character,  so  that  a  young  practitioner 
might  be  excused  for  overlooking  the  nature  of  the  case,  when 
distinct  large  or  small  red  spots  are  disseminated  over  the  white 
normal  surface  of  the  body.  TV^hen  the  spots  are  small,  scat- 
tered, and  dusky,  there  is  ground  for  alarm.  When  there  is  a 
well-developed  eruption  it  relieves  the  internal  organs  from  exces- 
sive oppression  by  the  fever-poison.  The  eruption  is  brightest  in 
healthy  and  strong  children,  whereas  in  the  feeble  it  is  limited, 
and  the  spots  approach  a  claret  hue.  The  eruption  of  scarlatina, 
as  well  as  the  constitutional  symptoms,  attain  their  height  b}^  the 
second  day  ;  the  eruption  begins  to  decline  on  the  fourth,  or  at  the 
latest  on  the  fifth  day,  when  the  throat  becomes  easier,  and  tran- 
quil sleep  returns. 

The  throat  of  scarlatina  is  never  so  painful  as  it  is  in  severe 
tonsillitis,  where  the  swelled  tonsils  almost  occlude  the  pharynx 
from  tumefaction  and  threatening  suppuration.*     The  tongue  is 

*  The  diagnosis  of  thethroat  affection  is  considered  in  Chapter  XXX,  On  Diphtheria, 


SCARLET   FEVER   OR  SCARLATINA.  117 

very  characteristic  in  most  cases,  but,  like  the  eruption,  does  not 
invariably  assume  the  same  appearance.  When  the  eruption  is 
brightest  and  inflammatory  fever  runs  high,  the  dorsum  and  centre 
are  covered  with  a  white  creamy  fur,  and  the  elongated  papillne 
project  through  the  deposit,  giving  the  tongue  the  appearance  of  a 
white  strawberr3^  The  temperature  frequently  runs  up  to  105° 
or  106°,  and  some  of  the  worst,  and  even  fatal  cases  in  children, 
have  not  exceeded  it.  It  has,  however,  been  known  to  exceed  112° 
in  fatal  cases.  The  fever  and  the  rash  appear  to  hold  a  close  re- 
lation to  one  another,  and  they  subside  simultaneously,  leaving 
the  patient  weak  and  languid.  In  the  decline  of  the  disease,  the 
urine  frequently  contains  albumen,  and  the  child  is  pale  and  thin. 
About  the  third  week  after  ajDparent  and  complete  recovery  from 
mild  scarlet  fever,  anasarca  and  albuminuria  may  set  in. 

3.  The  stage  of  desquamation. — The  skin  begins  to  peel  where 
the  eruption  first  made  its  appearance,  and  if  it  has  been  copious, 
the  old  epidermis  may  exfoliate  in  large  scales,  or  come  away  from 
the  fingers  like  a  glove;  the  process  is  a  very  slow  one,  and  if  pre- 
cautionary steps  are  not  taken  may  extend  over  many  weeks.  The 
mucous  membrane  also  participates  in  this  process,  by  the  escape 
of  phlegm  from  the  fauces,  and  epithelium  from  the  renal  passages. 
The  motions  at  this  period  are  also  putrid  and  ofiensive,  and  in- 
dicate the  profound  eftect  of  the  fever  poison  on  the  two  chief  ex- 
cretory channels. 

1.  Scarlatina  Simplex. — The  disease  begins  with  the  usual 
symptoms  of  fever:  thirst,  quick  pulse,  hot  skin,  headache,  pain 
in  the  back  and  limbs,  restlessuess  and  disturbed  sleep.  On  the 
second  day  of  the  fever,  a  bright -red  scarlet  effiorescence  appears, 
having  many  red  points,  which  are  not  elevated  above  the  surface 
of  the  body.  In  some  parts  these  small  points  run  together,  and 
cause  the  redness  to  be  general ;  whereas  in  other  parts  they  do 
not  coalesce.  The  eruption  is  first  seen  on  the  face,  neck,  and  ab- 
domen, and  especially  over  the  thorax  and  bends  of  the  joints.  On 
exposing  the  back  and  loins  it  may  be  often  seen  most  distinctly. 
The  eruption  disappears  on  pressure,  and  returns  at  once  when  it 
is  removed.  About  the  fifth  day  the  rash  declines,  and  by  the 
eighth  it  fades  and  disappears.  The  cuticle  begins  to  peel  and 
separate  about  the  fifth  day  from  the  parts  first  affected,  and  this 
process  may  continue  for  many  weeks.  The  hands  and  trunk  may 
be  seen  to  throw  off"  small  or  large  scales ;  and,  whilst  it  lasts, 


118  DISEASES   OF   CHILDREN. 

there  is  great  irritation  and  itcliing  of  the  skin.  At  the  commence- 
ment of  the  disease,  before  there  is  any  rash  on  the  body,  or  the 
throat  is  sore,  there  is  pain  and  difficulty  in  swallowing.  On  look- 
ing into  the  throat  the  tonsils  are  noticed  to  be  swelled  and  in- 
flamed, and  lymph  may  be  seen  adherent  to  them ;  there  is  diffused 
redness  of  the  soft  palate ;  the  uvula  is  also  red  and  elongated,  and 
the  pharynx  inflamed.  The  tongue  is  covered  with  a  thick  white 
fur,  and  the  jDapillse  may  be  seen  through  it.  Sometimes  in  the 
course  of  two  days  the  fur  disappears,  and  leaves  the  tongue  of  a 
strawberry  hue,  or  it  is  red  and  strawberry-looking  from  the  first. 
The  appearance  of  the  rash  is  not  attended  by  any  subsidence  of 
the  fever,  the  skin  being  hot  and  burning,  and  the  temperature 
elevated,  with  wandering  and  delirium  at  night ;  there  is  probably 
no  disease  in  which  the  temperature  runs  so  high.  Vomiting  is  a 
common  and  earlj"  symptom.  I  have  constantly  observed  it  before 
the  rash,  and  in  this  way  anticipated  the  disease.  The  pulse  is 
frequent,  full,  and  compressible,  and  ranges  from  120  to  140  in  a 
minute.  The  urine  is  scanty  and  high-colored,  containing  urates 
at  an  early  stage,  and  commonly  albumen  later  on.  During  the 
fever  the  amount  of  urea  and  uric  acid  excreted  by  the  urine  is 
increased,  while  that  of  the  chlorides  is  decreased.*  The  rash 
does  not  always  appear  on  the  second  day ;  it  may  be  delayed  in 
some  cases  till  the  third  or  fourth  day,  or  commence  on  the  first 
day  of  the  fever.  In  the  mildest  cases  there  is  little  else  noticeable 
than  a  general  erythema  of  the  skin ;  there  is  no  pain  in  swallow- 
ing, nor  inflammation  of  the  tonsils  or  pharynx,  or,  at  any  rate, 
the  reddening  of  the  throat  is  so  slight  that  it  may  well  escape 
attention.  The  eruption  comes  out  and  continues  the  usual  period, 
followed  by  desquamation. 

2.  Scarlatina  Anginosa. — Here  the  throat  is  more  severely  af- 
fected, and  the  submaxillary  glands  are  frequently  enlarged  and 
tender,  so  that  the  patient  has  pain  on  opening  his  mouth  or  in 
swallowing ;  the  tonsils  are  covered  with  a  fibrinous  or  sloughing 
exudation;  one  tonsil  maybe  more  aft'ecled  than  the  other,  or 
neither  may  be  implicated  in  this  way.  On  the  first  day  of  the 
fever,  before  the  rash  appears,  I  have  seen  the  right  tonsil  exca- 
vated by  a  deep,  ragged,  ashy-looking  ulcer,  and  the  tongue  loaded 
with  a  creamy  fur  at  the  back.     I  have  also  noticed  a  similar 

*  Clinical  Essays,  History  of  Scarlet  Fever. — Dr.  Kichardson,  Asclejjiad,  vol.  i,  p. 
114. 


SCARLET   FEVER   OR   SCART.AIINA.  119 

ulcer  on  the  fifth  day  of  eruption,  and  general  inflammation  of  the 
pharynx  and  uvula,  whilst  the  fur  is  cleaning  off  the  tongue. 
Mucus  collects  about  the  fauces  and  throat,  causing  troublesome 
hawking  and  spitting,  as  well  as  heavy  breathing,  and  the  inflam- 
mation extends  to  the  nose  or  runs  along  the  Eustachian  tube  to 
the  ear.  In  one  case  the  whole  external  ear  assumed  an  erysipel- 
atous redness,  and  there  was  much  deafness.  The  patient  recov- 
ered without  any  otorrhoja,  and  with  unimpaired  hearing.  As  in 
the  former  variety,  the  eruption  comes  out  on  the  second  day  of 
the  fever,  when  the  throat  usually  becomes  easier ;  the  eruption 
may  appear  first  on  the  arms  and  chest,  for  the  reason  probably, 
that  protected  parts  are  least  likely  to  be  chilled.  The  rest  of  the 
throat  may  now  be  swelled,  and  the  left  tonsil  may  present  two  or 
three  small  ashy  sloughs,  like  the  right.  The  pulse  may  reach  120 
or  140,  and  the  respiration  become  accelerated.  The  urine  at  this 
stage  is  turbid,  often  high-colored,  and  contains  a  large  quantity 
of  lateritious  sediment.  In  some  cases  the  swelling  of  the  throat 
increases,  and  the  voice  becomes  husky  and  weak,  though  the  pulse 
may  have  fallen  in  frequency.  On  the  third  day  of  the  fever  the 
eyelids  may  be  swelled,  and  the  conjunctivpe  so  inflamed  that  the 
patient  cannot  open  the  eyes;  it  leads  sometimes  to  ophthalmia 
tarsi,  and  repeated  small  abscesses  in  the  lids.  By  the  fifth  day 
the  extension  of  the  sloughing  may  have  ceased,  though  fresh 
portions  of  grayish  slough  may  fix  on  the  uvula,  and  on  any  sound 
part  of  the  tonsils.  The  skin  now  becomes  cooler,  and  the  tem- 
perature falls,  the  pufiiness  of  the  face  subsides,  and  the  tongue 
cleans.  The  cutaneous  irritation  at  this  stage  is  extreme,  and  in 
some  cases  prevents  the  patient  from  obtaining  any  rest  or  sleep. 
Severe  febrile  symptoms  may  arise  in  less  than  twenty-four  hours 
after  infection.  In  1869  I  was  summoned  to  a  young  person  who 
the  night  previous  was  in  good  health,  and  walked  and  drove  out. 
At  my  visit,  at  9.30  p.m.,  I  found  her  with  high  fever,  hot  and 
burning  skin,  great  thirst,  and  loaded  tongue  ;  pulse  120,  very 
weak,  tremor  in  the  legs,  and  prostration  of  strength.  Both  ton- 
sils and  uvula  were  much  swollen  and  inflamed,  and  on  the  right 
tonsil  was  a  patch  of  yellowish-looking  lymph.  There  was  pain, 
and  difficulty  in  deglutition,  but  no  hoarseness  or  enlargement  of 
the  glands  in  the  neck.  She  had  been  very  sick  in  the  early  part 
of  the  day,  and  brought  up  clear  bile.  The  following  day  the  face 
was  much  flushed,  and  a  copious  eruption  of  scarlet  fever  came  out 


120  DISEASES    OF   CHILDREN. 

on  the  chest,  abdomen,  shoulders,  and  loins  ;  the  skin  was  hot  and 
perspiring  ;  temperature  in  axilla  104°  ;  in  mouth  105°  ;  pulse  120, 
firmer  and  fuller.  She  could  speak  more  distinctly,  though  the 
swelling  of  the  throat  was  greater,  and  the  lymph  on  the  tonsils 
was  increased.  She  was  in  all  respects  more  comfortable  since  the 
eruption  had  appeared,  and  sickness  had  entirely  subsided.  For 
the  next  two  days  the  patient  remained  in  the  same  condition, 
when  the  throat  became  easier,  and  she  could  speak  with  ease  and 
clearness.  From  this  time  recovery  was  rapid,  and  the  convales- 
cence uninterrupted. 

In  some  cases  this  variety  of  scarlet  fever  is  attended  with  more 
severe  constitutional  symptoms  than  those  I  have  enumerated  ; 
sleep  is  disturbed,  and  exhaustion  sets  in  early  ;  the  pulse  is  fre- 
quent and  feeble,  the  secretion  of  urine  nearly  suppressed,*  and 
effusion  takes  place  into  one  or  more  of  the  chief  cavities  of  the 
body. 

Scarlatina  3Ialigna  (Cynanche  Maligna  of  Cullen). — This  is  the 
most  alarming  variety  of  all.  The  disease  concentrates  its  viru- 
lence on  the  throat  and  tonsils,  where  dark,  offensive  exudations 
form,  with  deep  ashy-looking  ulcers  and  sloughs.  The  pharynx 
uvula,  and  part  of  the  hard  palate  are  sometimes  seen  covered  with 
a  gangrenous  deposit,  and  a  bright-red  line  of  demarcation  is  visi- 
.ble.  Similar  ulceration  may  also  be  seen  on  the  inside  of  the  cheeks 
in  severe  cases ;  the  nostrils  also  become  inflamed,  and  furnish  a 
thin,  irritating  discharge,  which  inflames  and  excoriates  the  lip. 
The  salivary  glands  are  also  inflamed  and  swollen.  The  fever  at 
an  early  stage  of  the  disease  assumes  an  adynamic  type,  and  the 
constitutional  depression  is  severe.     There  is  wandering  and  drow- 

*  I  saw  in  consultation  a  little  boy,  in  1878,  who  on  the  fifth  day  of  the  eruption 
passed  only  two  teaspoonfuls  of  urine  in  twenty-four  hours,  containing  a  considerable 
quantity  of  bile  pigment  and  a  trace  of  albumen,  so  that  there  was  ample  proof  of  very 
defective  elimination.  The  patient  was  weak,  restless,  and  wandered  at  night ;  the 
throat  was  severely  affected,  and  there  was  a  difficulty  in  getting  him  to  take  nourish- 
ment. A  poultice  was  applied  to  the  loins,  and  next  day  a  free  secretion  of  urine  took 
place,  in  which  neither  bile  nor  albumen  could  be  detected.  Mr.  Nauglitin,  of  Baker 
Street,  informs  me  that  lie  attended  a  cbild,  aged  six  years,  in  1875,  who  did  not  pass 
urine  for  seven  days,  and  she  was  delirious  tlie  whole  time.  The  suppression  came  on 
ten  days  after  the  eruption  had  disa{)peared,  and  it  seemed  traceable  to  eating  heartily 
of  indigestible  food.  There  was  no  vomiting.  The  first  urine  passed  after  this  long 
interval  wa.s  about  a  teaspoonful,  and  approached  the  color  of  ink.  As  the  quantity 
increased  the  color  became  normal,  and  the  patient  experienced  no  subsequent  incon- 


SCARLET   FEVER   OR   SCAELATIXA.  121 

siness,  or  great  irritability  and  restlessness  ;  the  pulse  is  feeble  and 
rapid,  or  irregular;  tbe  tongue  drj,  brown,  and  chapped,  and 
sordes  may  be  seen  on  the  lips,  teeth,  and  gums.  The  temperature 
runs  high ;  in  a  fatal  case  under  ray  care  it  reached  lOS"^.  Some- 
times the  patient  dies  before  the  abortive  eruption  comes  out. 
There  is  no  uniformity  in,  the  time  of  its  appearance  or  in  its  char- 
acters; it  is  often  dark  and  in  irregular  patches,  or  it  may  be  pale 
and  bright  at  first,  and  then  change  soon  to  a  claret  hue,  some 
spots  being  larger  than  others,  and  there  are  also  observed  in  some 
cases  petechife,  which  prove  that  the  blood  is  much  changed.  The 
disease  in  many  cases  proves  fatal  on  the  third  or  fourth  day. 
How  far  this  variety  differs  from  the  others  in  its  real  nature  is 
still  an  undetermined  question.  Is  not  the  disease  the  same  in  all 
cases, —  a  distinct  fever,  brought  about  by  a  specific  poison,  but 
from  constitutional  predisposition,  locality,  physical  conditions,  or 
extreme  susceptibility  of  the  organism,  assuming  a  mild  or  a  severe 
form  ?  Epidemics  vary  in  their  severity,  and  produce  varieties  of 
type,  but  a  number  of  collateral  circumstances  must  be  ranged 
side  by  side,  before  we  can  admit  any  essential  difiference  in  the 
nature  of  the  disease. 

There  is  a  form  of  latent  scarlet  fever  {scarlatina  sine  eruptione) 
which  is  of  so  mild  a  character  that  the  disease  is  not  suspected 
till  the  general  health  show^s  signs  of  failure.  I  have  seen  chil- 
dren on  various  occasions  sufierino-  from  anaemia  and  general  de- 
bility,  with  or  without  albuminuria,  who  have  had  some  desqua- 
mation of  the  skin  without  the  specific  eruption.  In  one  case,  a 
little  girl,  who  w^as  said  to  have  escaped  the  disease  when  her 
brother  was  laid  up  with  it,  came  under  my  treatment  for  symp- 
toms of  general  debility.  Her  urine  was  scanty  and  non-albumi- 
nous, and  there  w- as  not  any  sign  of  anasarca,  but  I  could  not  avoid 
associating  her  state  with  the  probability  of  infection.  She  may 
have  had  some  sore  throat  and  feverish  disturbance,  but  they 
were  not  noticed  by  the  mother,  though  her  skin  w^as  rather  harsh, 
and  the  epidermis  inclined  to  peel  at  the  tips  of  the  fingers.  Cases 
of  anasarca  occasionally  come  under  our  notice  which  have  had 
their  origin  in  the  poison  of  scarlet  fever  without  any  eruption. 
The  absence  of  eruption,  and  the  slightness  of  the  illness,  have 
caused  the  child's  state  to  be  overlooked,  and  the  necessary  pre- 
cautions for  avoiding  cold  and  exposure  have  not  been  taken. 
These  patients  are  capable  of  communicating  the  disease  to  others. 


122  DISEASES   OF   CHILDEEN. 

As  reojards  tlie  pathology  of  the  disease,  I  may  here  give  the 
views  of  Dr.  John  Harley,*  who  describes  scarlatina  as  essentially 
a  disease  of  the  lymphatic  system.  How  far  these  views  may  be 
correct  appears  to  me  one  of  those  perplexing  questions  which 
further  observations  only  can  determine.  Dr.  Harley  gives  the 
post-mortem  appearances  in  twenty-eight  fatal  cases,  and  the 
morbid  changes  described  appear  in  many  of  them  to  resemble 
the  first  stage  of  enteric  fever.  The  glands  of  Peyer  (glandules 
agminatfe)  were  purple,  swollen,  and  vividly  injected,  and  the 
mucous  membrane  of  the  snlall  intestine  was  of  a  pale  or  bright 
rose  color.  The  solitary  glands  were  also  prominent,  and  of  a 
yellowish  color,  "  so  that  the  lower  third  of  the  ileum  appears  as 
if  sprinkled  with  grains  of  sago" — presenting  eminences  like 
hempseeds.  This  appearance,  which  French  writers  call  "Psoren- 
terie,"  was  observed  in  most  of  the  cases.  The  solitary  glands  or 
follicles  of  the  large  intestine  were  also  swollen  and  purple,  and 
the  caecum,  where  they  exist  in  the  greatest  number,  is  sometimes 
severely  congested  and  inflamed.  The  spleen  in  some  of  the  cases 
was  greatly  enlarged,  and  as  firm  as  liver,  the  mesenteric  glands 
were  likewise  turgid,  and  enlarged  to  the  size  of  a  pigeon's  egg, 
and  the  mesentery  has  been  found  converted  into  a  thickened 
lobulated  mass,  resembling  a  bag  of  large  or  small  marbles.  The 
right  cavities  of  the  heart  were  often  distended  with  blood,  and 
contained  colorless  clots  of  entangled  fibrin,  adherent  to  the  chordae 
tendinese,  and  continuing  through  the  auriculo-ventricular  opening. 
These  wormlike  clots  extended  into  the  pulmonary  artery,  the 
superior  cava,  and  larger  vessels  of  the  neck,  as  far  as  the  cranial 
cavity.  Branches  may  also  be  sent  into  the  lungs,  from  which 
they  may  be  withdrawn  eight  or  nine  inches  long.  The  same 
may  be  seen  in  some  cases  of  surgical  pyrexia  where  a  clot  is 
forming  in  the  heart.  Oppression  and  severe  pain  in  the  cardiac 
region,  orthopnoea,  a  rapid  and  feeble  pulse  with  an  alteration  in 
the  heart's  sounds,  indicate  that  a  deposit  is  taking  place. 

The  left  side  of  the  heart  in  the  twenty -eight  cases  alluded  to 
was  generally  found  empty  and  contracted ;  there  was  onlj'-  one 
case  in  which  a  fibrinous  clot  was  found  in  each  cavit}^ — in  this 
case  there  was  a  fibrinous  clot  on  both  sides.  The  tendency,  ac- 
cording to  Dr.  Richardson,  is  to  the  formation  of  clot  in  the  right 

*  Med.-Chir.  Trans.,  vol.  Iv,  p.  103.     The  Pathology  of  Scarlatina. 


SCARLET   FEVER   OR   SCARLATINA.  123 

cavities,  and  from  what  we  learn  in  some  other  diseases  where  the 
temperature  is  unusually  high,  it  is  what  we  should  expect. 

The  lungs  were  deeply  congested  in  some  of  the  twenty-eight 
cases,  and  points  of  ecch3miosis  were  seen  on  their  pleural  surface, 
and"  also  in  the  parietal  pericardium.  Pericarditis  and  pleuro- 
pneumonia are  occasionally  present.  Ileemorrhage  from  the  bowels 
was  the  cause  of  death  in  one  case,  and  scarcely  any  part  of  the 
mucous  membrane  was  healthy;  there  was  bright-red  villous  exu- 
dation, and  the  thin  vascular  membrane  came  away  exposing  the 
bowel,  which  was  blotched  and  spotted  with  ecchymosis.  General 
inflammation  of  the  mesenteric  glands  and  those  of  the  pleura  are 
constantly  observed,  and  profuse  diarrhoea  with  light  slimy  stools 
as  we  observe  in  tj'phoid  fever,  are  features  of  clinical  interest. 
Out  of  the  twenty-eight  cases,  more  or  less  albuminoid  or  fatty 
degeneration  of  the  kidneys  existed  in  six.  Most  of  the  patients 
died  from  the  third  to  the  sixth  day,  but  kidney  change  occurred 
in  no  case  before  the  fifteenth  day.  The  bile  was  found  normal 
only  in  five  cases  out  of  twenty;  in  the  remaining  fifteen  it  was 
much  deranged  ;  the  specific  gravity  was  low  (1014)  in  thirteen 
cases,  and  the  solid  matter  less  than  a  third  of  the  normal  amount ; 
the  biliary  acids  were  deficient,  but  the  coloring  matter  was  never 
absent. 

The  minute  pathological  anatomy  of  scarlatina,  according  to 
the  most  recent  researches  of  Klein,  consists  mainly  of  changes  in 
the  kidneys,  liver,  spleen,  and  Ijmiphatic  glands  of  the  throat.  In 
the  kidnej'S  there  is  a  proliferation  of  epithelium  cells,  and  changes 
in  the  walls  of  the  bloodvessels.  Later  on,  there  is  a  development 
of  round  cells  which  constitutes  a  true  interstitial  nephritis,  due 
to  an  embolic  process.  In  the  liver  there  is  also  a  growth  of  round 
cells  and  thickening  of  the  walls  of  the  bloodvessels,  with  an  in- 
filtration of  the  interlobular  and  intralobular  connective  tissue. 
In  the  cervical  glands,  there  is  inflammatory  swelling  and  multi- 
plication of  the  lymphatic  nuclei,  and  in  places,  large  giant  cells 
containing  several  nuclei.  There  is  also  a  hj^aline  thickening  of 
the  arterioles.* 

During  the  last  few  years  many  writers  have  noted  the  associa- 
tion of  scarlet  fever  with  enteric  fever,  or  one  has  so  rapidly 
followed  the  other,  that  they  have  been  naturally  regarded  as 
holding  some  relation  to  one  another.     The  cases  recorded  by  Dr. 


*  Trans.  Path.  Soc,  vol.  xxviii,  p.  430. 


124  DISEASES    OF    CHILDREN. 

Harley  show  that  scarlatina  coexisted  with  enteric  fever  in  a  few 
of  them,  and  that  rose  spots  were  distinguished  on  the  abdomen 
and  chest,  when  there  was  a  general  scarlet  rash  on  the  body. 
Papules  were  also  seen  distinctly  on  the  pallid  skin  after  the  scar- 
let blush  had  faded  away.  The  account  given  leaves  little  room 
for  doubt.  Diarrhoea  is  common  to  both  diseases  in  their  decline, 
and  the  evacuations  are  alike  in  character.  The  tongue  in  typhoid 
fever  often  presents  a  red  angry  appearance  with  enlarged  papillae, 
as  we  observe  in  scarlet  fever.  We  have  much  evidence  to  show 
that  mixed  cases  do  exist,  and  that  the  two  morbid  conditions 
cannot  be  separated  in  a  few  instances  where  the  febrile  process  is 
prolonged.  The  fact  of  diarrhoea  being  present  in  the  latter 
stages  of  the  disease  is  fully  explained  by  the  state  of  the  intes- 
tinal glands,  and  we  must,  I  think,  agree  with  Dr.  Harley  that 
this  morbid  change  is  one  of  the  strongest  proofs  that  a  patholog- 
ical relationship  does  exist  between  the  two  diseases,  which  acci- 
dental intercurrence  fails  to  explain. 

"Whatever  the  resemblance  of  the  pathological  states  may  be,  in 
some  cases,  such  as  Dr.  Harley  relates,  the  two  diseases  in  their 
local  and  general  signs  present  on  the  whole  a  striking  contrast. 
Jf  a  child  goes  on  well  for  the  first  week  or  ten  days  of  scarlet 
fever  he  commonly  gets  over  the  attack,  but  in  typhoid  fever  the 
disease  is  lingering  and  slow,  and  this  security  cannot  in  most 
cases  be  felt  till  some  weeks  have  elapsed.  There  are  crises  and 
relapses  which  expose  the  child  to  danger  till  convalescence  is 
permanently  established.  The  violence  of  this  short  fever  is  not 
80  alarming  as  in  some  others,  and  cannot  be  speedily  cut  short. 
It  is  less  alarming  in  scarlet  fever  than  in  almost  any  other  com- 
plaint. "Delirium,"  says  Dr.  Gairdner,  "is  apt  to  subside  of 
itself,  and  may  be  safely  neglected;  it  will  disappear  as  soon  as  the 
crisis  is  fully  established."  He  quotes  the  opinion  of  Heberden, 
who  also  entertained  the  view  that  there  "  was  no  disease  in 
which  the  patient  was  more  apt  to  be  delirious,  and  with  less 
danger,  than  in  scarlatina."*  Such  remedies  as,  antimony  and 
opium  are  out  of  the  question,  and  shaving  the  head  to  meet  the 
delirium  would  only  be  necessary  in  exceptional  cases.  When 
delirium  arises  the  little  patients  should  be  carefully  watched  and 
tended,  but  excessive  interference  is  bad  practice,  and  does  an 
infinity  of  harm. 

*  Clinical  Medicine,  by  Dr.  Gairdner,  1862,  p.  193. 


SCARLET   FEVER   OR   SCARLATINA.  125 

Causes. — These  are  due  to  the  influence  of  a  Sfiecific  and  highly 
contagious  poison.  The  poison  retains  its  power  for  a  considerable 
length  of  time,  and  the  clothes  worn  by  patients  suffering  from 
it,  as  well  as  carpets,  curtains,  etc.,  absorb  it.  There  can  be  no 
doubt  whatever  that  medical  men  sometimes  convey  it  from 
patient  to  patient,  and  so  carry  it  to  their  own  families.  Infec- 
tion is  as  great  at  the  beginning  as  during  the  time  of  desquama- 
tion, but  it  is  worthy  of  notice,  that  some  persons  are  more 
susceptible  to  infection  than  others,  and  that  a  severe  disease 
though  apt  to  produce  its  like,  may  also  result  from  a  mild  one. 

Children  at  the  breast  are  rarely  affected  by  scarlet  fever,  but 
such  eases  are  recorded ;  the  disease  is  more  prone  to  occur  about 
the  second  and  third  year,  though  there  is  very  little  difference  up 
to  five  years  of  age,  and  after  this  period  the  deaths  undergo  a 
remarkable  diminution,  but  nothing  like  that  observed  in  measles. 
Then  with  regard  to  the  proportion  of  deaths  in  the  two  sexes  : 
more  males  are  said  to  die  under  the  age  of  ten,  and  after  ten 
more  females ;  but  as  the  population  in  any  given  district  may 
vary  considerably  between  the  two  sexes  the  distinction  is  not 
easily  recognizable. 

As  to  the  influence  of  meteorological  conditions  most  writers 
agree  that  the  disease  is  most  prevalent  in  the  antunm,  and  lea-st 
in  the  spring ;  next  follow  the  summer  months,  and  lastly  the 
winter. 

The  average  annual  mortality  in  England  alone  from  this  ter- 
rible scourge  is  estimated  at  from  20,000  to  22,000.  It  is  greater 
in  towns  and  cities  than  in  rural  districts,  and  stands  highest  on 
the  list  of  communicable  diseases.  Then  follow  whooping-cough, 
measles,  and  small-pox  in  the  order  I  have  placed  them.  Although 
scarlet  fever  rarely  happens  a  second  time,  numerous  well-authen- 
ticated cases  are  placed  on  record.  When  it  does  happen  that  a 
child  is  seized  witha  recurrence  of  the  disorder,  it  is  exceptional, 
and  so  mild  in  its  nature  and  progress  that  it  never  proves  fatal. 

Concerning  the  recurrence  of  scarlet  fever  many  examples  are 
to  be  found.  A  case  occurred  in  the  London  Fever  Hospital 
under  the  care  of  Dr.  Broadbent,  where  the  patient  had  a  second 
attack  after  being  convalescent  from  a  first  attack,  and  whilst  the 
skin  was  still  desquamating.* 

A  similar  case  of  recurrence,  two  months  after  the  first  attack, 

*  British  Medical  Journal,  April  1st,  1876,  p.  411. 


126  DISEASES   OF    CHILDEEN". 

came  under  the  care  of  Mr.  Elkington  at  the  Birmingham  and 
Midland  Hospital  for  Sick  Children.*  The  child,  3  J  years  of  age, 
was  admitted  on  JS'ovember  22d,  1875,  suffering  from  a  large  ab- 
scess in  the  left  thigh.  There  was  a  history  of  scarlatinal  eruption 
and  sore  throat  six  weeks  previously,  and  the  patient  was  still 
desquamating.  The  temperature  on  admission  was  101:°.  On  the 
23d  the  abscess  was  opened  antlseptically,  and  two  ounces  of  thick 
creamy  pus  were  evacuated.  A  drainage-tube  was  inserted,  and 
for  the  next  eleven  days  all  went  well,  the  temperature  keeping 
normal  and  the  abscess  closing  quickly.  On  December  5th  the 
patient  had  headache,  sore  throat,  and  vomited  several  times  ; 
temperature  105°.  A  rash,  resembling  scarlatina,  was  visible  on 
the  chest,  arms,  and  neck,  and  there  was  great  congestion  of  the 
throat  and  tonsils.  On  the  6th  the  rash  was  fully  developed  over 
the  whole  body,  accompanied  by  intense  thirst  and  restlessness. 
Morning  temperature  103°,  evening  nearly  106°,  with  delirium. 
From  this  time  the  progress  was  favorable,  the  rash  fading,  and 
the  skin  desquamating  like  an  ordinary  case  of  scarlatina.  On 
the  13th  the  temperature  was  normal. 

There  are  no  more  obstinate  and  troublesome  sequelae  from  any 
of  the  diseases  of  childhood  than  those  which  follow  scarlet  fever. 
Otorrhoea  and  deafness,  enlarged  glands  in  the  neck,  ophthalmia, 
oz£ena,  eruptions  of  the  scalp,  acute  rheumatism,  and  chorea  are 
the  diseases  commonly  met  with.  Hypertrophy  of  the  tonsils  and 
persistent  ansemia  are  frequent  consequences.  However  slight  the 
symptoms  may  be,  troublesome  sequelae  are  apt  to  ensue,  and  this 
is  the  more  likely  to  happen  if  the  patient  quits  the  sick-room  too 
soon,  or  the  health  has  been  delicate  before  the  attack. 

In  1862  I  attended  a  girl,  seven  years  of  age,  who  was  seized 
with  the  most  severe  tyj^e  of  the  disease,  in  which  the  glands  of 
the  neck  were  greatly  implicated,  and  the  delirium  was  so  fierce 
and  continuous  that  her  life  was  despaired  of.  She  made  a  tedious 
recovery  through  having  an  abscess  on  the  right  side  of  the  neck, 
which  pointed  over  the  mastoid  process,  and  led  to  exfoliation  of 
the  temporal  bone.  Otorrhoea  continued  more  or  less,  and  pieces 
of  bone  came  away.  Twelve  years  elapsed  before  the  local  trouble 
was  cured  and  the  wound  healed,  but  now  the  hearing  is  perfect 
and  the  health  re-established  after  years  of  extreme  medical  care 
and  nursing,  which  only  the  wealthy  and  affluent  could  procure. 

*  British  Medical  Journal,  April  1st,  1876,  p.  411. 


SCAELET   FEVER   OR  SCARLATINA.  127 

My  experience  leads  nie  to  think  that  tuberculosis  can  be  more 
frequently  traced  to  scarlet  fever  than  is  generally  supposed.  Of 
all  the  sequelpe  anasarca  is  the  most  common, — an  infiltration  of 
serous  fluid  into  the  subcutaneous  areolar  tissue, — which  is  prone 
to  occur  in  some  parts  more  than  in  others.  If,  during  the  period 
of  desquamation,  the  patient  is  exposed  to  cold  from  incautiously 
venturing  out  too  soon,  and  a  chill  is  received,  the  escape  of  the 
fever-poison,  instead  of  taking  place  through  the  skin,  is  directed 
to  the  kidneys,  and  this  sets  up  irritation  and  acute  desquamative 
nephritis.  It  does  not  induce  this  in  all,  as  I  have  on  several  occa- 
sions seen  puffiness  of  the  lower  eyelids  at  the  end  of  three  weeks, 
and  swelling  of  the  glands  in  the  neck,  whilst  desquamation  was 
going  on  without  albuminuria.  With  the  kidney  affection  there 
is  headache,  pain  in  the  loins,  sickness  and  diarrhoea,  and  a  large 
quantity  of  albumen  in  the  urine,  which  may  be  clear  when  first 
passed,  or  turbid  and  loaded  with  urates.  It  may  vary  from  day 
to  day,  and  sometimes  contain  a  considerable  quantity  of  cayenne- 
pepper-looking  crystals  of  uric  acid ;  but  the  albumen  may  remam 
undiminished,  particularly  if  animal  food  is  indulged  in,  or  there 
is  any  other  error  in  diet.  Effusion  into  the  pleural,  pericardial, 
and  abdominal  cavities  is  common,  and  the  temperature  is  apt  to 
run  high.*  All  these  symptoms  may  improve  without  any  dimi- 
nution in  the  quantity  of  albumen. f 

A  serious  consequence  of  scarlatina  is  the  headache  of  ursemia, 
which  I  have  elsewhere  fully  considered.:}:  At  the  end  of  three  or 
four  years,  and  long  after  every  trace  of  dropsy  has  disappeared, 
the  child  so  manifestly  declines  in  health  and  spirits  that  the  at- 
tention of  parents  is  at  last  awakened  to  his  altered  condition. 
He  is  unable  to  pursue  his  studies  at  home  or  to  continue  at  school, 
and  he  has  no  inclination  to  join  in  the  pleasures  of  his  playmates. 

*  Vide  Chap.  XXIV,  On  Acute  Desquamative  Nephritis,  and  (Edema  of  Lungs, 
Chap.  XXVIII. 

f  "The  percentage  of  kidney  complications  in  scarlet  fever  varies  from  five  to  seven- 
teen. Frerichs  has  described  a  rare  form  of  dropsy  without  any  disease  of  the  kidneys 
occurring  after  scarlet  fever,  which  he  believes  to  be  due  to  paralysis  of  the  cutaneous 
nerves  by  exposure  to  cold  during  desquamation,  and  I  have  lately  seen  one  such  case, 
where  repeated  examination  of  the  urine  revealed  no  change,  whilst  there  was  very 
acute  dropsy  of  the  skin,  without  any  effusion  into  cavities,  which  lasted  twelve  days." 
— Steiner  on  Diseases  of  Children,  by  Lawson  Tait,  p.  341. 

X  Headaches,  their  Nature,  Causes,  and  Treatment,  by  W.  H.  Day,  M.D.,  3d  edit. 
Toxemic  Headache,  chap.  ix. 


128  ■  DISEASES    OF    CHILDREN". 

A  severe  and  continuous  frontal  headache  ensues,  and  the  child 
loses  his  vivacity  and  interest  in  everything.  The  veins  are  full 
about  the  head  and  lips,  in  some  cases,  and  there  is  a  set  color  on 
the  cheeks.  The  urine  is  scanty  and  contains  albumen,  with  renal 
casts  and  eiDitheliura;  it  varies  greatly  in  some  cases,  the  deposit 
thrown  down  some  days  being  very  considerable,  and  at  other 
times  barely  perceptible.  Indulgence  in  animal  food  is  prone  to 
cause  renal  congestion  in  these  cases,  with  an  aggravation  of  the 
head  s^miptoms,  and  there  is  associated  with  it  sometimes  dilata- 
tion and  hypertrophy  of  the  left  ventricle,  increased  tension  in  the 
pulse,  perceptible  to  the  finger,  but  more  accurately  estimated  by 
a  sphygmographic  tracing.  For  the  treatment  of  this  complica- 
tion the  reader  is  referred  to  the  chapter  on  albuminuria. 

Treatment — The  treatment  of  mild  cases  consists  in  confinement 
to  bed,  a  mild  aperient,  and  cooling  drinks.  Rest  in  bed  and  judi- 
cious nursing  will  carry  most  children  safely  through  the  attack. 
With  regard  to  purgatives  and  active  reruedies,  they  have  less 
influence  over  this  disease  than  some  other  febrile  affections,  and 
the  pulse  will  continue  quick,  and  the  temperature  high  in  spite 
of  them.  If  the  bowels  are  costive  and  the  stomach  loaded,  an 
active  purgative  may  be  necessary.  I  give  preference  to  purga- 
tive remedies,  especially  at  the  onset  of  the  disease.  But  at  the 
commencement  of  the  disease,  and  in  its  early  stages,  if  it  is  at  all 
severe,  the  chief  indication  is  to  promote  a  free  action  of  the  skin 
till  the  child  is  bedewed  with  perspiration.  If  this  could  be  ob- 
tained, it  would  be  the  best  remedy  at  our  command,  by  favoring 
the  excretion  of  the  morbid  poison  before  it  had  time  to  damage 
any  internal  organ,  and  produce  those  changes  in  the  blood  which 
sometimes  lead  to  fibrinous  deposition  in  the  heart.  A  hot-air 
bath  ma}"  be  speedily  constructed,  as  in  croup,  and  it  should  be  so 
arranged  that  the  child's  face  is  exposed  to  the  pure  air,  which 
should  circulate  freely  through  the  room.  In  hot  weather,  during 
the  rising  of  the  fever,  free  ventilation  of  the  sick  apartment  is  not 
apt  to  induce  cold,  but  when  desquamation  has  set  in  there  is 
great  susceptibilit}-. 

I  am  here  constrained  to  point  out  the  value  of  the  action  of 
aconite  in  reducing  fever  and  inflammation,  from  the  influence  it 
exerts  in  bringing  down  the  temperature  and  lessening  blood  pres- 
sure. From  what  we  know  of  its  power  in  subduing  fever  in  some 
cases  of  surgical  pyrexia  it  is  unquestionably  a  remedy  of  great 


SCARLET  FEVER   OR   SCARLATINA.  129 

value,  and  if  we  consider  the  tendency  which  the  blood  has  to 
coagulate  in  its  passage  through  the  central  organ  of  the  circula- 
tion, it  might  be  advantageously  resorted  to  in  the  early  stages  of 
this  disease.  It  brings  down  the  pulse,  and  promotes  a  free  action 
of  the  skin,  and  encourages  the  loss  of  heat  by  evaporation.  In 
some  cases  it  reduces  fever  and  inflammation,  as  in  tonsillitis, 
without  promoting  perspiration.  I  fully  agree  with  Dr.  Fother- 
gill,  that  the  specitic  action  of  aconite  is  exerted  on  the  vascular 
system,  by  paralj'zing  the  vasomotor  nerves  and  lessening  the  con- 
tractility of  the  vessels.  If  then  it  has  the  power  of  dilating  the 
vessels,  and  by  drawing  the  blood  towards  them  diminishing  the 
tension  in  an  inflamed  part,  it  ought  to  be  employed  where  this 
condition  is  present.  All  who  have  given  the  remedy  a  fair  trial 
in  catarrh,  sore  throat,  and  inflammation  of  the  tonsils,  will  be 
willing  to  admit,  that  it  converts  with  marvellous  rapidity,  a  dry 
and  burning  skin  into  one  that  is  moist  and  sweating,  and  in  this 
way  it  relieves  the  restlessness  and  constitutional  disturbance. 
Aconite  is  of  most  service  and  can  be  more  advantageouslj^  em- 
ployed when  the  pulse  is  hard,  and  the  action  of  the  heart  strong 
and  violent.  My  own  experience  of  the  action  of  aconite  is,  that 
it  lessens  the  frequenc}^  and  increases  the  fulness  of  the  pulse ;  it 
reduces  the  hardness  and  incompressibility.  Half  a  minim  in  a 
teaspoonful  of  water  for  a  child  should  be  given  every  hour,  but 
should  the  pulse  become  weak  or  irregular,  or  there  be  any  sign 
of  weakness  or  prostration,  it  ought  to  be  discontinued.  The  indi- 
cation for  givi)]g  aconite  is  elevation  of  temperature,  for  where  it 
is  present  there  is  fever  or  inflammation  ;  when  the  temperature 
is  normal  or  nearly  so,  it  should  not  be  employed,  but  when  it 
shows  indications  of  rising,  and  the  pulse  though  not  more  fre- 
quent becomes  more  resisting,  it  may  be  prescribed.  Durina: 
scarlet  fever,  or  after  it,  when  kidney  complication  has  arisen, 
aconite  may  be  given,  for  if  it  does  not  shorten  the  fever  it  soothes 
the  nervous  system,  and  by  promoting  free  perspiration  controls 
the  inflammation  that  attends  it,  and  moderates  the  throat  aft'ec- 
tion.*     When  the  throat  is  dusk}^  and  much  swollen,  and  the 

*  It  is  doubtful  whether  aconite  will  shorten  the  fever  of  acute  specific  diseases,  as 
scarlet  fever,  measles,  etc.,  but  it  has  a  beneficial  influence  in  these  diseases,  soothing 
the  nervous  system,  and  favoring  sleep,  by  inducing  free  perspiration.  Whether  this 
remedy  can  lessen  the  severity  of  the  fever,  or  diminish  the  duration  of  the  acute  specific 
diseases,  is  doubtful ;  but  there  is  no  doubt  it  can  control  and  subdue  the  inflammatory 

9 


130  DISEASES    OF    CHILDREN. 

symptoms  assume  a  typhoid  character,  aconite  would  be  too  de- 
pressing, and  the  local  disorder  is  best  treated  by  the  application 
of  nitrate  of  silver  or  the  diluted  tincture  of  the  perchloride  of  iron. 
Internally,  the  iron  and  chlorate  of  potash  mixture  recommended 
in  diphtheria  will  be  found  invaluable.     (Form.  54.) 

Some  years  ago  Dr.  Richardson  advocated  the  value  of  liquor 
ammonia,  from  its  power  in  holding  the  fibrin  of  the  blood  in 
solation,  and  keeping  it  in  a  fluid  state.  A  few  drops  of  the  Liquor 
Ammonife  in  water,  with  or  without  the  addition  of  the  Liquor 
Ammonise  Acetatis,  is  the  form  he  recommends  to  be  given.  Both 
these  remedies  tend  to  eliminate  carbonic  acid  by  the  breath  and 
skin,  but  they  require  caution  in  their  administration,  lest  the  free 
ammonia  interfere  with  oxygenation,  and  break  up  or  damage  the 
red  corpuscles  of  the  blood. 

In  Scarlatina  anginosa,  if  there  is  reason  to  think  the  digestive 
organs  are  loaded,  and  the  tongue  is  heavily  furred,  an  emetic 
should  be  given  at  the  onset.  A  grain  or  two  of  calomel  and  an 
active  aperient  may  be  ventured  upon,  if  the  pulse  is  full  and 
strong,  and  the  inflammatory  fever  runs  high.  Milk  and  soda 
water  to  drink  frequentlj^,  ice  to  suck,  beef  tea  and  chicken  broth 
will  be  demanded.  Warm  linseed  poultices,  or  even  two  or  three 
leeches,  to  the  throat  will  be  advisable,  if  there  is  swelling  about 
the  jaws,  or  pain  in  swallowing.  Eflervescing  medicines,  such  as 
carbonate  of  ammonia  and  lemon-juice,  are  refreshing  and  agree- 
able to  take. 

Sponging  the  body  with  vinegar  and  tepid  water  (one  in  four), 
or  iced  water,  if  the  temperature  runs  high,  should  be  practiced 
three  or  four  times  a  day.  I  prefer  this  milder  practice  to  cold 
efl:usions,  or  cold  wet  packing,  which,  so  far  as  my  experience  goes, 
are  only  to  be  adopted  in  exceptional  cases.  The  treatment  by 
cold  water  has  proved  curative  in  this  variety  of  scarlet  fever  when 
cerebral  symptoms  are  present,  and  coma  threatens ;  no  other 
remedy  except  cold  having  the  power  to  reduce  the  hyperpyrexia, 
as  in  those  cases  of  rheumatism,  where  a  dangerous  rise  of  tem- 
perature takes  place.*    This  plan  should  be  adopted  when  all  other 

affections  which  often  accompany  them,  and  wliich,  by  their  severity,  may  endanger 
life.  Thus  aconite  will  moderate,  but  neitlicr  prevent  nor  shorten  the  course  of  the 
inflammation  of  the  throat  in  scarlet  fever,  and  the  catarrh  and  bronchitis  in  measles, 
and  in  this  indirect  manner  lessen  the  height  of  the  fever. — Dr.  Ringer's  Handbook  of 
Therapeutics,  4th  edition.  Aconite,  p.  435. 

*  See  Chap.  XLIII,  "  On  Acute  Rheumatism." 


SCARLET   FEVER   OR  SCARLATINA.  131 

remedies  fail,  and  the  skin  is  extremely  hot,  the  pulse  full,  and 
there  is  drowsiness,  convulsions,  or  delirium.  It  is  better  to  im- 
merse the  patient  in  tepid  water  tirst,  and  gradually  cool  it  by  the 
addition  of  ice.  The  etfects  of  the  bath  on  the  temperature  should 
be  carefully  w^atched,  the  patient  not  being  kept  in  it  for  more 
than  ten  minutes  at  one  time.  If  there  is  delirium  and  a  tendency 
to  coma,  the  scalp  may  be  shaved,  and  cold  lotions  applied  to  the 
head.  In  this  form  of  the  disease,  depression  soon  sets  in,  and 
port  wine,  beef  tea,  champagne,  and  soda-water  will  be  required. 

For  the  throat  affection,  if  the  patient  is  old  enough  to  manage 
it,  a  gargle  of  chlorate  of  potash  and  dilute  hydrochloric  acid  will 
correct  the  unhealthy  exudation  that  hangs  about  the  throat,  but 
in  the  case  of  very  young  children  this  cannot  be  used,  and  then 
mopping  out  the  fauces  with  a  solution  of  nitrate  of  silver  (gr.  x 
to  the  5J)  twice  a  day  will  be  effectual  in  most  mild  cases,  or  a 
weak  solution  of  chlorinated  soda  may  be  substituted. 

The  inhalation  of  the  steam  of  hot  water  as  long  as  the  throat 
is  sore,  is  a  safe  and  excellent  practice,  and  according  to  Dr.  Gaird- 
ner,  supersedes  almost  all  other  local  applications.*  The  inhalers 
used  for  this  purpose,  however  useful  and  easy  of  application  for 
adults,  are  somewhat  alarming  and  difficult  for  very  young  chil- 
dren. The  steam-draft  inhaler  brought  before  the  notice  of  the 
Medical  Society  of  London,  by  Dr.  R.  J.  Lee,  is  well  adapted  in 
these  cases. f 

When  the  exudation  is  of  an  ashy  color  and  inclined  to  extend, 
the  solution  of  perchloride  of  iron,  applied  ou  a  sponge  with  for- 
ceps, will  exert  an  excellent  effect.  It  should  be  used  night  and 
morning  at  least,  and  after  two  or  three  applications,  the  throat 
will  assume  a  more  healthy  appearance,  and  the  fetor  of  the  breath 
w^ill  diminish.  In  very  young  children,  it  is  necessary  to  apply 
the  solution  lightly,  and  to  limit  its  application  to  the  diseased 
surface,  for  if  any  roughness  is  employed,  and  great  care  is  not 
taken,  the  healthy  parts  are  irritated,  and  the  soreness  and  inflam- 
mation increased.  The  diluted  solution  for  children  is  generally 
strong  enough  ;:j:  but  this  may  be  left  to  the  discretion  of  the 

*  Clinical  Medicine,  Scarlet  and  Enteric  Fever,  p.  196. 
f  Medical  Society  Proceedings,  vol.  iv,  p.  201. 
X  Formula  10 : 

R.  Liq.  Ferri  Perchlor., §j 

Glycerini. 

Aquse,  aa .         .         .     ^ss. — M. 

Fiat  solutio. 


132  DISEASES    OF    CHILDREN. 

practitioner,  as  where  tlie  throat  is  dark  and  much  implicated,  I 
should  not  hesitate  to  employ  the  pure  solution  (Liq.  Ferri  Per- 
chlor.,  B.  P.). 

In  cases,  however,  where  the  jaws  are  stiff  from  the  swelling,  or 
the  child  resists  obstinatelj^,  or  is  exhausted,  it  is  perhaps  better  to 
desist  from  local  interference  with  the  throat.  If  a  case  of  this 
difficult}^  presents  itself,  the  carbolic  acid  spray  is  one  of  the  best 
applications.  When  foul  secretions  collect  about  the  fauces,  and 
cannot  be  thrown  off  by  any  eflbrts  of  the  little  patient,  the  spray 
ought  to  be  employed.  It  both  cleanses  and  disinfects.  As  it  is 
of  the  utmost  importance  that  the  patient  should  breathe  as  pure 
an  atmosphere  as  possible,  it  is  evident  that  if  the  air  becomes  con- 
taminated before  it  reaches  the  lungs  (as  it  will  do  if  the  throat  is 
covered  Avith  decomposing  secretions)  the  child's  life  is  placed  in 
still  greater  jeopardy.  The  vulcanite  spray  producer,  as  sold  by 
surgical  instrument  makers,  is  of  great  service  in  all  inflammatory 
or  irritative  aiiections  of  the  throat,  larynx,  and  bronchi.  It  is 
easy  of  application,  and  causes  neither  pain  nor  inconvenience. 
The  vulcanite  end  must  be  introduced  between  the  teeth  and  above 
the  tongue,  because  a  young  child  will  not  open  its  mouth  when 
bid.  Then  with  gentle  pressure  on  the  hand-ball,  a  steady  and 
uniform  stream  of  carbolic  spray  can  be  kept  up  and  maintained, 
if  compression  is  made  about  once  in  every  second.  It  acts  directly 
on  the  diseased  tissues,  and  gradually  penetrates  deeper  than  any 
gargle  or  other  similar  mode  of  application ;  causing  neither  pain 
nor  irritation  to  the  inflamed  and  sensitive  throat.  I  give  prefer- 
ence to  carbolic  acid,  but  other  medicinal  agents  ma}^  be  used.  In 
cases  of  throat  affection  due  to  the  exanthemata,  I  have  seen 
excellent  effects  follow  the  use  of  the  spray  vaporizer — the  respira- 
tion and  the  power  of  swallowing  rapidly  improving,  and  patches 
of  slough  and  exudation  expectorated.  In  young  children  I  have 
on  several  occasions  known  life  saved  by  it,  and  it  is  a  remedy  to 
be  held  in  remembrance.  Three  or  four  inhalations  may  be  used 
in  the  space  of  twenty-four  hours,  and  the  strengtii  of  the  liquid 
may  vary  from  one  in  twenty  to  one  in  forty.  For  fear  of  fatiguing 
the  child,  each  application  should  not  exceed  three  or  four  minutes. 
Soon  after  its  use,  I  have  known  a  child,  previously  on  the  verge 
of  coma  and  breathing  rapidly,  wake  up  lively,  and  from  that 
time  improve,  till  a  repetition  of  the  same  application  was  de- 
manded by  a  relapse  of  the  sj^mptoms. 


SCAELET   FEVER   OR   SCARLATINA.  133 

Meigs  and  Pepper  recommend  a  decoction  of  stronjr  green  tea 
and  alum,  or  sage  tea  and  alum,  or  lime-water,  or  honey  of  roses 
and  borax.*  Sir  T.  Watson  a  solution  of  chloride  of  soda.f  Dr. 
"West  one  part  of  hydrochloric  acid  to  six  parts  of  honey,  by 
means  of  a  dossil  of  lint  or  a  camel's-hair  brush,  two  or  three 
times  a  day.:]:  For  the  coryza,  any  of  the  astringent  washes  used 
for  the  throat,  or  a  solution  of  nitrate  of  silver — gr,  j  or  gr.  ij  to 
5j  of  water,  thrown  up  the  nostrils  every  four  hours.§ 

In  Scaiintina  maligna  the  treatment  must  be  of  a  supporting 
character  from  the  first,  and  ammonia,  bark,  iron, ||  port  wine,  and 
brandy  are  required  to  be  given  freely.  There  is  here  a  tendency 
to  failure  of  the  heart's  action,  either  from  debility  and  exhaustion, 
or  from  fibrinous  deposit  in  its  cavities. 

Sir  Thomas  Watson  recommends  in  scarlet  fever  a  chlorine  drink, 
now  well  known  to  the  profession.  It  is  composed  of  eight  grains 
of  chlorate  of  potash,  one  drachm  of  hydrochloric  acid,  and  one 
pint  of  water.  A  child  ten  years  of  age  may  have  it  rather  more 
diluted,  and  take  half  the  quantity  during  the  da3^  The  chlorine 
possesses  disinfecting  properties,  and  the  solution  renders  the  foul 
secretions  which  collect  upon  the  fauces  less  noxious  and  hurtful, 
and  the  tongue  becomes  clean  and  moist. ®[[  Or  the  following  mix- 
ture may  be  used :  Put  an  ounce  of  chlorate  of  potash  and  the 
juice  of  two  moderate-sized  lemons  into  an  ordinary  wine  bottle, 
and  fill  up  with  Avater.  A  wineglassful  may  be  given,  or  taken, 
two  or  three  times  a  day  by  the  patient  and  by  those  in  attendance. 

For  the  dropsy  that  follows  scarlatina,  warmth  and  a  milk 
diet  are  to  be  adopted.  An  occasional  aperient  of  compound  jalap 
powder  in  the  morning,  and  small  doses  of  tincture  of  digitalis 
with  acetate  of  potash  during  the  day  should  be  given,  if  the 
urine  is  scanty  and  high-colored,  or  contains  any  blood.  If  there 
is  pain  in  the  loins,  a  vapor-bath  or  a  poultice,  applied  every  night 

*  Diseases  of  Children,  1874,  p.  754. 

t  Principles  and  Practice  of  Medicine,  vol.  ii,  p.  909,  4th  edit. 

X  Diseases  of  Infancy  and  Childhood,  p.  732.  §  Ibid. 

II  Formula  11: 

R.  Amm.  carb.,  .........     gr.  viij 

Tinct.  cinch,  corap., ^ij 

Syr.  aurant.,         . ^iij 

Aqnam  ad      .........         .     ^^iv. — M. 

A  dessert  or  tablespoonful  every  four  hours.     For  a  child  four  or  five  years  old. 

T[  Principles  and  Practice  of  Medicine,  4th  edit.,  vol.  ii,  p.  910. 


134  DISEASES   OF   CHILDREX. 

should  be  emploj-ed."^  When  the  urine  is  clear,  though  albumin- 
ous, and  the  febrile  symptoms  have  departed,  the  tincture  of  per- 
chloride  of  iron  (Form.  53)  should  be  given,  and  if  the  child  loses 
flesh,  and  there  is  no  sickness  or  diarrhoea,  cod-liver  oil  will  be  a 
useful  adjunct.  For  the  efl'usions  that  are  liable  to  occur  in  the 
pleural  or  pericardial  cavit}^,  diuretics  and  tonics  are  to  be  em- 
ployed, and  all  those  remedies  which  encourage  the  action  of  the 
excretory  organs,  and  improve  the  qualitj'  of  the  blood  at  the  same 
time.  When  an  attack  of  scarlet  fever  and  its  consequences  have 
passed  awa}^,  the  patient  should  wear  flannel  next  the  skin^  and  go 
to  the  seaside  for  change  of  air.  Flowever  well  a  child  may  be 
going  on,  after  a  severe  case,  a  mouth  or  six  weeks  ought  to  elapse 
before  it  goes  out  of  doors,  and  even  then  the  weather  should  be 
considered. 

For  many  months  after  an  attack  of  scarlet  fever,  and  it  may 
even  be  for  an  indefinite  time,  there  will  be  observed  in  some 
cases,  especially  those  marked  b}^  ansemia,  a  faint  and  persistent 
trace  of  albumen,  with  no  other  morbid  change  in  the  urine,  as  tube 
casts  or  renal  epithelium.  This  condition  awakens  some  anxiety, 
though  it  may  continue  for  twentj^  years  without  any  manifest 
impairment  of  the  general  health.  When  anemia  is  present,  I 
strongl}^  advocate  the  steady  use  of  the  tincture  of  the  perchloride 
of  iron,  and  in  some  instances,  where  renal  congestion  is  easily 
provoked,  the  addition  of  gr.  -^^  of  perchloride  of  mercury  three 
times  a  day.  AYhen  the  diet  is  carefully  regulated  and  cold 
avoided,  perfect  recovery  may  take  place,  but  there  will  be  no 
chance  of  this,  unless  stimulants  are  prohibited,  and  milk  and 
white  fish  take  the  place  of  meat. 

Xow,  as  to  some  precautionary  measures  in  arresting  the  spread 
of  this  disorder.  Isolation  of  the  patients  suffering  from  scarlet 
fever  is  one  of  the  chief  circumstances  to  be  borne  in  mind  in  order 
to  prevent  its  extension.    The  apartment  in  which  the  sick  person 

*  See  Chap.  XXIV,  "On  Acute  Desquamative  Nephritis."  In  the  Practitioner  fur 
August,  1876,  Dr.  de  Havilland  Hall  has  recorded  an  interesting  case  of  acute  desquam- 
ative nephritis  following  scarlet  fever,  in  which  the  patient,  a  boy  nine  years  of  age, 
passed  no  water  for  fifty  hours  after  admission,  and  from  his  mother's  account  very 
little  had  been  passed  previously.  Tlie  entire  absence  of  any  of  the  symptoms  of 
uraemia  in  tlie  case  was  attributed  in  part  to  the  fact  that  all  articles  of  nourishment, 
except  a  little  milk  and  a  free  supply  of  water,  were  withheld.  The  only  medicinal 
treatment  was  a  dose  of  Pulv.  Jalapas  Co.  and  a  drachm  of  bitartrate  of  potash  as  a 
drink. 


SCARLET    FEVER    OR   SCARLATINA.  135 

is  confined  should  be  well  ventilated,  and  curtains,  carpets,  and  all 
unnecessary  articles  of  furniture  should  be  removed.  The  bed 
linen  and  that  worn  by  the  patient  should  be  changed  daily,  and 
placed  at  once  into  a  deep  common  hip  bath,  under  water,  so  that 
the  desquamating  epidermis  may  be  less  likely  to  propagate  infec- 
tion. I  recommeiid  a  weak  solution  of  carbolic  acid  to  be  thrown 
into  the  bath,  and  two  or  three  saucers  containing  it  to  be  put  in 
the  sick-room  and  various  parts  of  the  house.  I  also  insist  on  the 
importance  of  adding  disinfectants  to  the  evacuations,  and  getting 
rid  of  them  directly.  With  these  precautions  I  have  often  known 
the  disease  not  to  spread.  Infection  persists  so  long  as  there  is 
the  least  trace  of  desquamation,  and  to  insure  safety,  isolation 
should  be  enforced  for  at  least  a  week  after  the  last  particle  of 
exfoliated  cuticle  has  been  detached. 

Dr.  Wm.  Budd's*  directions  for  limiting  the  spread  of  the  disease 
are  well  known  to  the  professsion  His  paper  is  so  full  of  interest, 
and  his  directions  so  eminently  practical,  that  I  shall  quote  the 
chief  precautions  which  he  enforces. 

1.  The  room  is  to  be  dismantled  of  all  needless  woollens  or  other 

draperies,  which  might  possibly  serve  to  harbor  the  poison. 

2.  A  basin  charged  with  chloride  or  carbolate  of  lime,  or  some 

other  convenient  disinfectant,  is  to  be  kept  constantly  on 
the  bed,  for  the  patient  to  spit  into. 

3.  A  large  vessel,  containing  water  impregnated  with  chlorides 

or  with  Condy's  fluid,  should  always  stand  in  the  room,  for 
the  reception  of  all  bed  and  body  linen  immediately  on  its 
removal  from  the  person  of  the  patient. 

4.  Pocket  handkerchiefs  are  proscribed,  and  small  pieces  of  rag 

are  used  instead  for  wiping  the  mouth,  and  nose.  Each 
piece  after  being  once  used  is  to  be  immediately  burnt. 

5.  As  the  hands  of  nurses  of  necessity  become  frequently  soiled 

by  the  specific  excreta,  a  good  supply  of  towels,  and  two 
basins,  one  containing  water  with  Condy's  fluid  or  chlorides, 
and  another  plain  soap  and  water,  are  always  to  be  at  hand, 
for  the  immediate  removal  of  the  taint. 

6.  All   glasses,  cups,  or  other  vessels,  used  by   or   about   the 

patients,  are  to  be  scrupulously  cleaned  before  being  used 
by  others. 

*  Scarlet  Fever  and  its  Prevention,  Brit.  Med.  Joiirn.,  1869,  vol.  i,  p.  23. 


136  DISEASES    OF    CHILDEEX. 

7.  The  discharges  from  the  bowels  and  kidnejs  are  to  be  received, 
071  their  very  issue  from  the  body,  into  vessels  charged  with 
disinfectants. 

Dr.  Bndd  considers  that  by  these  means  the  infectious  power 
of  the  germs  is  destroj-ed  as  they  emanate  from  the  skin,  the 
surface  of  which  is  so  extensive,  that  the  poison  escaping  b}''  it  is 
far  greater  than  that  which  is  cast  off  by  all  the  other  surfaces  of 
the  body  combined.  An  impalpable  powder  armed  with  the  subtle 
poison  of  scarlet  fever,  floats  in  the  atmosphere  and  conveys  infec- 
tion to  an}^  person  who  may  be  within  the  sphere  of  its  influence. 
To  prevent  the  escape  of  these  particles  from  the  body  and  carrying 
the  poison  far  and  near,  Dr.  Budd  strongly  advises  anointing  the 
body  and  scalp  with  olive  oil  impregnated  with  camphor  twice  a 
day.  As  soon  as  the  skin  begins  to  peel  (and  this  is  sometimes  as 
early  as  the  fourth  daj^)  the  oiling  should  be  commenced,  and  con- 
tinued till  the  patient  is  well  enough  to  take  a  warm  bath,  when 
the  whole  body  and  head  should  be  well  scrubbed  with  disinfect- 
ing soap  (Calvert's  or  McDoughall's).  The  baths  are  to  be  repeated 
every  other  day  until  four  have  been  taken,  when,  if  the  patient 
has  new  clothes,  and  there  is  no  throat  or  kidney  complication,  he 
may  return  without  risk  to  his  family  in  a  week  or  ten  days. 
After  this  the  sick-room  should  be  well  fumigated,  and  the  bedding 
or  curtains  exposed  to  a  high  temperature  (240°  or  250°),  which  is 
said  effectually  to  destroy  the  power  of  the  specific  poison.  The 
principles  advocated  by  Dr.  Budd  apply  to  all  contagious  fevers, 
as  small-pox,  measles,  typhus,  etc.,  and  the  method  employed  has 
proved  so  successful  in  his  hands,  that,  during  a  period  of  twenty 
years,  he  had  not  known  the  disease  to  spread  beyond  the  sick-room. 

"  Hanging  rags  steeped  in  disinfectant  solution  about  the  room 
is  not  to  be  commended,  but  a  sheet  moistened  with  a  strong  solu- 
tion of  chloralum,  carbolic  acid,  or  Condy's  fluid,  and  suspended 
outside  the  door  of  the  room,  is  very  necessary  to  complete  the 
isolation  of  the  patient.  .  .  .  Care  must  also  be  taken  in  using 
different  disinfectants  that  they  do  not  counteract  each  other  ;  for 
example,  carbolic  acid  decomposes  Condy's  fluid."* 

The  prophylactic  powers  of  belladonna,  which  have  been  vaunted 
for  preventing  an  attack  of  scarlatina,  are  so  fanciful  that  I  do 
not  attach  importance  to  the  statements  that  have  been  made  iu 
favor  of  it. 

*  Handbook  of  Uygiene,  by  Dr.  Wilson,  second  edition,  1873,  p.  304. 


VARIOLA   OR  SMALL-POX.  137 

CHAPTER    XIT. 

VARIOLA   OR    SMALL-POX. 

Theee  principal,  Vabieties  generai>ly  described:  1.  Variola  discreia  or  dis- 
tinct small-pox — 2.  Variola  confluens  or  conjlueni  small-pox — 3.  Variola  hcemorrhagica. 
1.  Variola  discreta  has  three  distinct  stages — (1)  The  stage  of  incubation — (2)  The 
stage  of  eruption — (3)  The  stage  of  desquamation.  2.  Variola  confluens  ushered  in 
with  more  severe  constitutional  symptoms,  and.  irregularity  in  the  appearance  of  the  rash 

—  Contents  of  the  pustules  and  occasional  implication  of  the  cellular  tissue  beneath — 
Danger  of  the  secondary  fever  and  affection  of  the  throat  and  salivary  glands.  3.  Vari- 
ola hcemorrhagica  or  black  .small-pox,  met  with  during  the  prevaltnre  of  a  severe  epidemic 

—  Varioloid  or  modified  small-pox;  its  symptoms  and  general  character.  Causes: 
Small-pox  due  to  a  specifie  poison' from  a  person  infected,  with  it,  and  communicable  by 
iuocxdation.  Prognosis  and  Complications  :  Mortality  and  morbid  appearances 
found  after  death.  Treatment  :  Importance  of  keeping  the  apartments  cool  and  well 
ventilated — Value  of  disinfectants — U-'ic  of  emetics  and  purgatives  in  the  ea>iy  .stages — 
Remedies  for  the  relief  of  itching  and  local  irritation — Management  of  restlessness  and 
delirium — Local  inflammation  and  collection  of  matter — Applications  to  the  throat  and 
fauces — -Frequency  of  boils — Diarrhoea — Prevention  of  pitting — Ophthalmia. 

Small-pox  is  a  highly  contagious  febrile  disease,  following  a 
definite  and  uniform  course,  which  after  a  latent  period  passes 
through  the  stages  of  pimple,  vesicle,  pustule,  and  scab.  Since 
the  introduction  of  vaccination  this  disease  has  become  compara- 
tively rare  ;  and  if  this  preventive  measure  is  efficiently  carried 
out  there  is  every  reason  to  hope  that  it  will  gradually  become  ex- 
terminated. In  this  country  it  is  compulsory  to  vaccinate  by  the 
third  month,  and  as  very  young  children  are  especially  subject  to 
the  disease,  and  it  spreads  with  alarming  force,  the  law  cannot  be 
too  stringently  observed  where  the  health  is  good.  Older  persons 
who  have  been  successfully  vaccinated  are  in  a  great  degree  exempt 
from  the  disorder,  and  they  may  enjoy  immunity  from  it  if  revac- 
cinated  when  growth  is  completed,  or  VN'hen  an  epidemic  prevails. 
When  a  person  who  is  unprotected  by  vaccination  is  exposed  to 
the  contagion  of  small-pox,  he  may  contract  the  most  malignant 
form,  according  to  the  state  of  his  health  and  the  type  of  the  dis- 
ease that  prevails.  Three  varieties  of  small-pox  are  usually  de- 
scribed : 

1.  Variola  discreia,  or  distinct  small-pox. 

2.  Variola  confluens,  or  confluent  small-pox. 

3.  Variola  haimorrhagica. 

1.    Variola  discreta,  or  the  milder  type,  has  three  stages  like 


138  DISEASES    OF    CHILDREN. 

other  exantliematoLis  affections.  (1.)  The  stage  of  incubation. 
(2.)  The  stage  of  eruption.     (3.)  The  stage  of  desquamation. 

1.  The  Stage  of  Incubation. — Fourteen  clays  usually  elapse  between 
the  time  when  the  poison  is  received  into  the  system  and  the 
aj3pearance  of  the  eruption.*  Two  days  preceding  the  eruption 
the  constitutional  symptoms  are  marked  by  a  rigOr,  severe  head- 
ache, loss  of  appetite,  and  thirst,  but  they  are  sometimes  over- 
looked, and  in  a  few  instances  I  have  seen  children  brought  for  an 
opinion  about  the  characier  of  a  small-pox  eruption  wdiich  covered 
the  face,  and  caused  but  little  derangement  in  the  general  health. 
There  is  usually  the  history  of  a  day's  malaise  before  the  spots 
appear,  and  where  a  child  is  seen  during  this  doubtful  period, 
there  is  always  such  rise  of  temperature  as  warrants  rest  in  bed, 
and  a  cautious  diagnosis.  Generally  some  symptoms  of  gastric 
disorder  precede  the  outbreak  of  the  exanthem,  as  a  thick-coated 
tongue,  vomiting,  and  irregularity  of  the  bowels  ;  pain  in  the  back 
and  loins,  constantly  observed  in  adults,  cannot  be  ascertained  in 
young  children,  as  if  the  question  is  put  they  are  certain  to  com- 
plain of  it.  At  this  time  the  accompanying  febrile  excitement  is 
always  shown  by  tlie  clinical  thermometer.  Then  disturbances 
ensue  in  the  nervous  and  vascular  system  ;  the  skin  feels  hot  and 
pungent,  and  there  is  headache  and  restlessness — headache  is  a 
constant  and  severe  sj-mptom.  Sometimes  there  is  delirium  or 
convulsions,  and  a  torpid  or  even  comatose  condition,  from  which 
it  is  not  easy  to  rouse  the  child.  The  pulse  is  quick  and  full,  120 
to  140,  and  towards  evening  the  febrile  exacerbations  become 
greater,  and  the  temperature  rises  to  101°  or  105°,  the  eyes  are 
suffused  and  heavy,  and  then  tlie  eruption  makes  its  appearance, 
which  occurs  earlier  in  severe  than  in  mild  cases.  Sometimes  a 
roseolous  rash  precedes  the  characteristic  eruption,  which  has 
received  the  name  of  "  roseola  variolosa,"  and  then  it  may  be  im- 
possible to  diagnose  it  from  measles. 

The  eruption  first  shows  itself  on  the  face,  in  the  form  of  small 
red  elevated  papules  resembling  measles.     Soon  an  elevation  takes 

*  In  three  cases  mentioned  by  Dr.  Murcliison,  the  incubation-period,  dating  from  . 
the  time  the  poison  entered  tlie  system  till  the  first  symptoms  appeared,  was  thirteen 
daj's  in  two  cases,  and  eleven  days  in  one  case,  so  that  tlie  latent  period  is  subject  to 
variation,  as  it  is  in  all  of  the  infections  diseases.  Of  eighteen  cases,  the  shortest 
incubation-period  was  five  days  in  one  case,  eleven  days  in  five  cases,  and  thirteen 
days  in  one  case. — Observations  on  the  Period  of  Incubation  of  Scarlet  Fever,  and  of 
some  othen  Diseases,  Clin.  Trans.,  1878,  p.  238. 


VARIOLA   OR   SMALL-POX.  139 

place  in  the  centre  hy  the  development  of  a  small  tubercle,  and  by 
the  second  day,  it  attains  the  size  of  a  pin's  head,  and  imparts  a 
feeling  of  small  shot  to  the  finger.  On  the  third  day,  it  is  as 
large  as  a  lentil  and  extends  over  the  rest  of  the  face  and  neck,  to 
the  shoulders,  trunk,  and  extremities.  The  eruption  is  darker  and 
most  abundant  where  the  parts  are  exposed  or  uncovered,  and  on 
protected  parts,  as  the  body  or  feet,  it  is  of  a  light  rose  color. 
About  the  fifth  day,  a  small  vesicle  containing  a  clear  fluid  forms 
on  the  top  of  each  pimple — it  is  tense,  like  a  small  blister,  but 
soon  becomes  depressed  in  the  centre,  with  an  inflamed  areola  or 
base  surrounding  the  elevated  pimple.  All  the  points,  or  papules, 
do  not  pass  through  the  same  process  of  change,  as  some  of  them 
never  reach  the  stage  of  maturation,  but  pass  away  in  the  course 
of  a  few"  days,  especially  on  the  legs  and  feet.  The  excitement 
and  inflammatory  fever  now  quickly  subside,  the  pulse  is  reduced 
in  frequency,  the  secretions  become  more  natural,  and  the  cerebral 
disturbance  passes  off.  On  or  about  the  sixth  day,  there  is  sore- 
ness and  swelling  of  the  throat  with  difficulty  in  swallowing,  and 
the  rash  and  small  circular  white  spots  may  be  seen  on  the  fauces. 
This  does  not  occur  in  all  cases.  The  throat  is  sometimes  free, 
though  the  attack  is  a  severe  one.  The  face  and  eyelids  swell,  so 
that  the  features  of  the  patient  are  no  longer  to  be  recognized. 
On  or  about  the  eighth  day,  the  central  depression  disappears,  and 
the  contents  of  the  vesicles  become  purulent,  the  redness  of  the 
areola  is  more  extensive,  and  the  face  more  swelled  and  bloated.^ 
In  cases  that  pursue  a  satisfactory  course,  a  brown  spot  forms  in 
the  centre  of  the  pustule,  which  attains  its  full  size  by  the  ninth 
day,  the  areola  around  the  base  becomes  less  inflamed,  and  the 
pufliness  of  the  features  disajjpears.  At  the  same  time  the  face 
and  hands  begin  to  swell.  The  pustules  now  rupture  and  the 
escape  of  their  contents  dry  up  into  scabs,  which  fall  off  in  the 
course  of  four  or  five  days,  beneath  which  the  skin  is  of  a  pur- 

*  "Each  well-formed  pustule,  when  carefully  dissected,  will  be  seen  to  consist  of  two 
compartments,  the  upper  one  being  the  larger.  These  compartments  are  both  filled 
with  pus,  and  communicate  with  each  other  at  the  marginal  borders.  This  septum  is 
a  layer  of  false  membrane,  deposited  in  the  derma  at  an  early  stage  of  the  disease, 
which,  by  removing  the  surface-layer  of  the  pustule,  is  brought  into  view,  presenting  a 
bright  red  or  purple  color,  and  is  highly  infecting.  Eut  the  mature  surface  is  multiloc- 
ular,  and  when  a  transverse  section  is  made,  presents  an  appearance  that  has  been 
compared  to  a  severed  orange.'' — Vogel,  Diseases  of  Children,  1874,  p.  499.  Tra'nsla- 
tor's  remarks. 


140  DISEASES    OF    CHILDREN. 

plisli  color,  whicli  lasts  for  a  considerable  length  of  time.  The 
bursting  and  desiccation  of  the  pustules  begin  first  on  the  face, 
and  gradually  pass  downwards  to  the  trunk  and  extremities. 
Scratching  the  surface  prevents  children  from  giving  the  pustules 
a  chance  of  drying  up  without  bursting.  The  swelling  of  the 
hands  and  feet  passes  off,  and  the  patient  is  convalescent  by  the 
seventeenth  or  eighteenth  day.  If  the  case  is  a  severe  one,  and 
the  child  has  not  been  vaccinated,  a  permanent  depression  or  scar 
is  left  in  the  skin  marking  the  situation  of  each  pustule.  This 
becomes  covered  with  a  new  epidermis,  and  the  cicatrices  appear 
very  marked  in  children,  but  as  they  grow  older,  the  skin  being 
thin  and  elastic,  the  depressions  are  not  so  apparent.  About 
the  eighth  daj",  when  the  vesicle  has  become  pustular,  a  secondary 
or  suppurative  fever  appears ;  the  face  is  more  swelled  and  inflamed, 
the  pulse  is  quick  and  weak,  the  tongue  inclined  to  drj'ness,  and 
the  temperature  considerably  elevated. 

The  urine  is  scanty  and  high-colored*  and  the  bowels  consti- 
pated, so  that  the  little  patient  becomes  restless,  or  even  delirious 
at  night ;  the  surface  itches  to  such  an  extent  that  the  child 
scratches  and  tears  open  the  pustules  unless  the  greatest  precau- 
tions are  taken. 

2.  Variola  Conflaens  or  Confluent  Sniall-'pox. — This  variety  of 
the  disease  is  more  severe  than  that  just  described.  It  sets  in  with 
more  severe  rigors,  with  fever,  headache,  and  delirium.  The 
secondary  fever  is  also  of  a  tj'phoid  character,  and  there  may  be 
coma  and  jactitation.  The  rash  does  not  appear  with  the  regu- 
larity of  the  milder  affection  ;  a  red  erythematous  blush  appears  on 
the  skin,  and  on  the  second  day,  small  red  points  may  be  seen,  and 
the  pustules  are  not  distinct  but  run  together  and  are  flat.  They 
often  contain  a  thin,  brownish,  ichorous  discharge,  instead  of  puru- 
lent matter.  The  cellular  tissue  beneath  maj^  be  involved  in  severe 
inflammation  and  slouo-hino-,  and  the  swelliuo;  of  the  face  and 
salivation  begin  earlj^  in  the  disease.  The  secondary  fever  is  much 
more  dangerous  than  in  the  first  form,  and  quickly  assumes  a 

*  Tlie  urinary  secretion  in  tlie  eruptive  and  suppurative  stages  may  contain  traces 
of  allMimen,  which  indeed  is  common  to  tlicse  periods  in  some  otiier  of  the  exanthe- 
mata. Becquerel  states  that  it  is  normal  during  desquamation,  but  in  the  putrid  form 
of  the  disease  "it  is  decomposed  and  ammoniacul,"  and  ma.y  sometimes  contain  blood. 
But  tliis  is  simply  due  to  the  hsematuria,  which  we  have  seen  to  be  common  when  the 
poison  is  of  a  very  malignant  character,  arid  is  part  of  the  same  condition  which  pro- 
duces ecchymoses  of  the  conjunctivae  and  petechise  on  the  skin. 


YAEIOLA    OR   S.MALL-POX.  141 

typhoid  character.  The  eruption  is  dark  and  livid,  and  petechi{« 
are  common,  as  well  as  hremorrhages  from  the  mucous  surface  of 
the  bowels  or  bladder.  The  exhaustion  increases,  and  the  patient 
perhaps  dies  convulsed,  or  in  a  state  of  coma.  In  cases  of  recovery" 
the  cicatrices  are  deeper,  and  the  deformity  greater.  In  one  case 
of  extreme  severity  that  came  under  my  care  some  years  ago,  the 
outline  of  the  nose  was  completely  effaced,  and  the  eyelids  infil- 
trated with  serum  and  covered  with  pustules.  The  fauces,  mouth, 
and  nose  were  similarly  affected,  and  the  tongue  was  so  swelled 
that  it  could  not  be  retained  within  the  mouth.  The  neck  and 
cervical  glands  were  swollen,  and  viscid  saliva  was  constantly 
pouring  out  of  the  mouth.  This  distressing  condition  had  only 
lasted  a  few  hours,  when,  in  making  an  ineffectual  attempt  to 
swallow^  a  little  fluid  that  had  been  put  into  the  mouth,  the  patient 
was  seized  with  suffocative  symptoms,  and  died  instantly. 

3.  There  is  yet  another  variety  termed  Variola  hcemorrh.agica 
or  black  small-pox,  which  is  occasionally  met  "with  in  severe  epi- 
demics. Bright  red  petechiae  occur  upon  the  skin  about  the  size 
of  a  pin's  head  coincident  with  the  appearance  of  the  papules,  which 
become  darker  and  of  a  purple  hue  on  the  third  or  fourth  day  of 
the  disease,  when  a  spot  of  purpura  or  of  haemorrhage  occupies  the 
pustule.  White  pustules  may  be  seen  on  the  fauces  and  palate. 
Htemorrhage  from  the  mucous  surface  of  the  vagina,  bowels,  and 
urinary  passages  (h?ematuria)  distinguish  the  disease.  The  mind 
is  collected,  and  death  occurs  on  the  third  or  fourth  day  of  the 
disease.  Congestion  of  the  chief  internal  organs  is  seen  in  the 
lungs,  mesenteric  glands,  and  spleen,  and  ecchymoses,  like  the 
petechia  on  the  skin,  are  scattered  over  the  intestines.  Soft  clots 
are  found  in  the  right  side  of  the  heart,  while  the  left  is  empty. 
These  cases  are  rare,  but  they  occur  in  every  severe  epidemic,  and 
when  once  seen  cannot  readily  be  mistaken,  though  they  may  be 
overlooked,  in  consequence  of  death  happening  before  the  rash  is 
well  developed. 

Varioloid  or  modified  small-pox  is  the  term  used  when  the  disease 
happens  a  second  time,  or  the  patient  has  been  protected  by  vacci- 
nation. The  fever  lasts  only  a  day  or  two,  and  the  eruption  ap- 
pears in  the  morning,  the  general  health  being  slightly  deranged 
the  day  before.  A  few  scattered  pimples  appear  on  the  forehead, 
face,  and  nose  ;  some  of  them  become  vesicles,  and  others  shrivel 
up,  whilst  on  different  parts  of  the  body  they  present  various 


142  DISEASES   OF   CHILDEEl!f. 

stages  of  imperfect  development.  The  rapid  fall  of  temperature 
on  the  second  or  third  day  as  the  rash  appears,  distinguishes  it 
from  typhus  and  from  measles.  Unless  the  rash  is  extensive  there 
is  no  secondary  fever. 

The  cause  of  small-pox  is  due  to  a  specific  poison  from  a  person 
laboring  under  the  disease,  or  from  clothes  left  ofi'by  the  sick  and 
worn  by  the  health3^  It  is  conveyed  b}'-  the  atmosphere  and  is 
caught  from  vehicles  in  which  diseased  persons  have  ridden.  It 
may  be  communicated  by  inoculation  or  by  the  scabs  from  the 
sick.  "  Most  likely  it  is  communicable  from  the  moment  when 
the  initiatory  fever  begins.  It  may  be  given  by  the  breath  of  the 
patient  before  the  eruption  has  appeared  on  the  surface  of  the 
body.  It  continues  infectious  so  long  as  any  of  the  dry  scabs  re- 
sulting from  the  original  eruption  remain  adherent  to  the  body  ; 
a  single  breathing  of  the  air  where  it  is,  is  enough  to  give  the  dis- 
ease. The  dead  body  for  several  days  after  death,  has  been  known 
to  communicate  the  disease,  and  in  all  probability  it  would  pro- 
duce the  disease  for  some  months  afterwards."* 

Small-pox  seldom  attacks  the  same  person  a  second  time,  not 
one  per  cent,  being  liable  to  a  recurrence  of  it.  The  disease  may 
attack  the  foetus  in  utero. 

As  to  the  prognosis  of  the  disease,  it  is  favorable  in  the  vac- 
cinated, if  three  or  four  good  vaccination-marks  remain,  if  the 
disease  is  mild  and  distinct,  and  if  the  children  are  strong  and 
health3^  It  is  unfavorable  if  vaccination  have  never  been  per- 
formed, or  if  there  be  only  one  or  two  faint  marks  of  a  single  vac- 
cination ;  if  the  symptoms  assume  a  confluent  form,  and  the  pus- 
tules are  dark  and  flattened.  A  sudden  disappearance  of  the  rash, 
with  prostration  of  the  strength,  and  a  rapid  feeble  pulse,  are 
indications  of  danger ;  and  where  they  are  present  the  typhoid 
state  continues,  and  leads  to  death  by  syncope,  convulsions,  or 
coma.  Inflammatory  affections  of  the  brain,  pneumonia,  and  sup- 
puration of  some  of  tlie  viscera,  are  among  the  modes  of  fatal 
termination. 

Death  most  commonly  occurs  in  small-pox  after  the  primary 
fever,  and  seldom  before  the  twelfth  day — the  most  frequent  com- 
plications are  meningitis,  and  aft'ections  of  the  thoracic  organs, 
severe  diarrhrca,  and  lesions  of  the  intestinal  canal,  and,  according 
to  Vogel,  gangrene  of  the  mouth  is  sometimes  present.f 

*  Keynolds's  System  of  Medicine,  vol.  i,  2d  edit.,  p.  242. 
f  Diseases  of  Children,  p.  491. 


VARIOLA   OR   SMALL-POX.  143 

The  mortality  from  tins  disease  increases  with  age; "while  it  is 
very  fatal  at  the  extremes  of  life.*  Much  will  depend  upon  the 
age  and  constitution  of  the  child,  and  whether  it  has  been  pre- 
viously vaccinated  or  not.  Where  it  is  neglected,  the  child  gets  a 
severe  attack,  and,  if  it  recovers,  bears  through  life  the  most  dis- 
figuring cicatrices.  In  the  case  of  a  mother  and  child,  who  came 
under  my  notice  some  years  ago,  the  former,  who  was  protected 
bj^  vacciiiation,  had  only  a  few  small  spots  on  her  face,  and  made 
no  complaint  of  her  health  bej^ond  slight  lassitude  and  disordered 
digestion  ;  whilst  the  latter,  who  was  four  months  old,  and  suckled 
by  the  mother,  had  her  face  covered  with  the  eruption,  and  the 
body  and  limbs  were  also  much  involved.  The  child  recovered, 
but  to  this  day  the  face  is  frightfully  pitted  by  the  numerous  cica- 
trices. 

Of  the  morbid  appearances  found  in  those  who  have  died  of 
small-pox,  evidences  of  inflammation  are  met  with  in  the  intestinal 
canal,  the  bronchial  tubes,  and  various  parts  of  the  brain,  in  con- 
sequence of  a  deteriorated  state  of  the  blood,  which  is  found  liquid, 
dark,  and  uncoagulated.  Universal  congestion  of  the  internal 
organs  is  also  present,  and  the  liver,  spleen,  and  kidneys  contain  a 
ffreat  deal  of  blood.  The  brain  and  membranes  are  cons-ested,  and 
the  sinuses  full  of  blood.  Pustules  or  false  membrane  may  be  seen 
in  the  mouth,  tongue,  fauces,  and  pharynx,  and  throughout  the 
oesophagus  to  the  rectum,  beneath  which  the  membrane  is  infiaraed 
and  vascular.  Evidence  of  inflammation  in  the  interior  of  the  heart 
and  pericardium  is  also  to  be  noted,  and  a  change  in  the  nmscalar 
structure  leading  to  granular  or  fatty  degeneration. 

Treatment. — There  is  no  disease  in  which  it  is  more  necessary  to 
keep  the  apartment  cool  and  ventilated.  In  the  winter  season  of 
the  year  there  should  be  a  fire  in  the  room,  and  the  windows  opened 
from  time  to  time,  and  so  managed  that  the  patient  may  not  be 
exposed  to  draughts  of  cold  air.  In  the  summer,  when  the  weather 
is  hot  or  sultry,  the  windows  should  be  opened  at  the  top,  and 
curtains  and  carpets  be  removed.  Disinfectants,  in  the  shape  of 
carbolic  acid,  Condy's  fluid,  or  chloride  of  lime,  should  be  placed 
in  saucers  and  put  in  the  room  and  passages  of  the  house.  All 
these  important  precautions  ought  to  be  strenuously  enforced. 

Before  the  eruption  makes  its  appearance  the  treatment  should 

*  "  According  to  Dr.  Marson,  patients  of  all  ages  die  at  tlie  rate  of  50  per  cent,  in 
the  confluent,  and  8  per  cent,  in  the  semi-confluent,  and  4  per  cent,  in  the  discrete 
variety." — Hooper's  Fhysician^s  Vade  Mecum.  Dr.  Guy  and  Dr.  Harley.  Article, 
Variola,  p.  305. 


144  DISEASES    OP    CHILDREN". 

be  directed  to  moderate  the  fever  aud  subdue  the  nervous  excite- 
ment. To  attain  this  object  an  emetic  may  be  given,  followed  by 
a  mixture  of  sulphate  of  magnesia  with  nitrate  of  potash  (Form. 
8),  or  infusion  of  senna,  to  control  the  fever  and  open  the  bowels 
freely.  If  the  child  is  strong  and  there  is  constipation  a  grain  or 
tW'O  of  calomel,  followed  by  a  draught  of  sulphate  of  magnesia  and 
senna,  should  be  ordered.  In  mild  cases  a  dose  of  castor  oil,  or  a 
draught  of  rhubarb  and  magnesia,  will  be  sufficient  to  .clear  the 
bowels  of  an}^  irritant  matters. 

If  the  disease  happens  in  hot  weather,  and  there  is  much  thirst 
and  soreness  of  the  throat  in  sw^allowing,  weak  tea  and  milk  with 
toast  will  be  sufficient  nourishment  for  a  day  or  two,  and  grapes, 
strawberries,  and  iced  lemonade  may  be  taken  freely.  Raspberry 
vinegar  is  an  excellent  drink  and  relished  by  all  patients. 

During  the  period  of  eruption  aud  maturation  the  measures  to 
be  employed  are  much  the  same;  and,  if  there  is  restlessness  and 
irritation  of  the  skin,  it  is  a  good  plan  to  use  a  warm  bath,  to 
which  oatrneal  or  carbonate  of  soda  is  added.  If  itching  and  irri- 
tation of  the  face  are  severe  it  shoukl  be  smeared  over  with  olive 
oil,  or  olive  oil  to  which  carbolic  acid  (1  in  40)  is  added,  or  glj^c- 
erin,  or  zinc  ointment.  Pork  lard  melted  in  a  saucer  and  applied 
to  the  face  allays  irritation  in  a  remarkable  manner.  If  the  strength 
appears  deficient  it  must  be  supported  by  suitable  nourishment,  as 
beef  tea,  chicken  broth,  and  so  forth.  When  the  fever  subsides  a 
stimulating  diaphoretic  may  be  giveu.*  If  the  child  is  restless  at 
night  bromide  of  potassium  or  hydrate  of  chloral  at  bedtime  should 
be  employed,  for  if  the  patient  cannot  obtain  sleep  he  will  become 
exhausted  and  the  restlessness  will  increase.  Opiates,  however, 
must  be  used  wnth  great  caution.  For  the  delirium  which  arises 
in  the  course  of  small-pox,  care  should  be  observed  in  noticing 
whether  it  is  due  to  a  plethoric  state,  with  a  full  pulse  and  active 

*  Formula  12: 

R.  Liquor  aram.  acet., ^ss. 

Spt.  aether,  nitr.,       ........     3j 

Syr.  rosse, .         .     giij 

Aquam  ad ,^iv. — M. 

A  tablespoouful  every  four  hours.     For  children  five  years  of  age. 
Formula  13 : 

R.  Amm.  carb., gr.  viij 

Liquor  amm.  acet., 

Syr.  aurant.,  aa         .......         .     ^ss. 

Aquam  ad        ........         .     5iv. — M. 

A  tablespoonful  every  four  hours.     For  cliildren  five  years  of  age. 


VARIOLA   OR   SMALL-POX.  145 

cerebral  excitement,  or  whether  the  child  is  weakly  and  delicate, 
and  the  pulse  quick  and  running,  so  that  each  beat  is  not  appre- 
ciably distinct.  In  the  former  case  cokl  sponging  or  ice  to  the 
head  may  be  required ;  in  the  latter  case  stimulants  and  nourish- 
ment, with  quinine  if  the  temperature  be  high,  are  the  only  reme- 
dies to  subdue  it. 

Local  inflammation  must  be  treated  on  general  principles. 
"Where  collections  of  matter  form,  whether  in  the  cellular  tissue 
or  under  the  scalp,  they  should  be  opened  early  to  prevent  their 
spreading,  and  cavities  may  be  washed  out  with  carbolic  acid  lo- 
tion (1  in  40)  or  nitrate  of  silver  (gr.  x  to  the  5J).  The  discharge 
from  the  pustules  in  severe  cases  is  very  irritating  and  causes  much 
discomfort.  To  meet  this  the  linen  cannot  be  too  frequently 
changed,  and  oxide  of  zinc  and  starch  in  equal  proportions,  or 
calamine  powder  and  oxide  of  zinc,  or  flour,  or  some  of  the  toilet 
powders  in  use,  may  be  dusted  over  the  body  from  a  common 
dredger.  For  the  vomiting,  which  sometimes  occurs,  iced  water 
or  prussic  acid  is  useful ;  and  if  the  child  is  old  enough  an  effer- 
vescent mixture,  and  a  poultice  to  the  epigastrium.  If  the  throat 
is  much  swollen  two  or  three  leeches  may  be  applied,  and  after- 
wards a  i^oultice.  Mopping  out  the  throat  with  a  weak  solution 
of  nitrate  of  silver,  or  the  infusion  of  roses  with  sulphuric  acid,  is 
also  to  be  recommended. 

Boils  frequently  result  from  small-pox,  and  they  are  tedious  to 
heal.  The  discharge  exhausts  the  patient  and  prolongs  his  con- 
valescence. When  this  complication  has  arisen  quinine  and  bark 
will  be  required  to  support  the  strength.  The  mineral  acids  with 
tincture  of  gentian  often  ansvver  well,  and  the  wounds  should  be 
dressed  with  some  stimulating  ointment.  If  sloughing  takes  place 
a  carrot  or  a  linseed  poultice  should  be  applied,  and  the  free  use  of 
carbolic  acid  or  Condy's  fluid  should  not  be  omitted. 

When  the  eruptive  fever  has  passed  away,  and  there  are  languor 
and  clammy  skin,  the  mineral  acids  with  bark  or  calumba  will  be 
serviceable.*     When  the  strength  begins  to  fail  tonics  and  stimu- 

*  Formula  14: 

R.  Acid,  nitric,  dil., 

Acid,  liydrochl.  dil.,  ha,  .         .         .         .         .         .         .     ^ss. 

Tinct.  cinch,  co.,  vel  tinct.  calunibse,         ....     giij 

Syrupi, 3ss. 

Aquara  ad        ........         .     ^iv. — M. 

A  tablespoonful  three  times  a  day.     For  children  five  years  of  age. 

10 


146  DISEASES    OF    CHILDEEX. 

lants  will  be  needed.  Quinine  and  ammonia  are  the  best,  and  wine 
and  brand}^  according  to  the  exigencies  of  the  case. 

In  the  hsemorrhagic  variety  of  the  affection,  the  free  use  of  stimu- 
lants, and  supporting  measures  of  all  kinds  are  demanded.  In  the 
shape  of  medicine  some  styptic  preparations  of  iron,  as  the  tincture 
of  the  perchloride,  should  be  given  to  restrain  the  haemorrhage. 

When  diarrhoea  is  excessive  it  should  be  checked  by  krameria,* 
small  doses  of  laudanum,  or  the  Pulvis  Cretse  c.  Opio.f 

The  prevention  of  pitting  is  no  insignificant  part  of  the  treat- 
ment. The  parts  affected,  jiarticularly  the  face,  should  be  protected 
from  the  air,  and  the  lymph  let  out  from  the  distended  vesicles  by 
a  needle,  and  absorbed  by  cotton-wool.  The  top  of  each  pustule  is 
to  be  lifted  up,  and  a  thin  point  of  nitrate  of  silver  applied  to  the 
base.  The  remedj^  to  be  successful  should  be  applied  on  the 
second  or  third  day  of  eruption,  and,  though  it  causes  some  pain, 
it  soon  passes  off,  and  diminishes  the  swelling  and  tumefaction  of 
the  pustules,  and  prevents  cicatrices.  Of  the  application  of  mer- 
curial ointment  to  prevent  pitting,  Rilliet  and  Barthez  state,  that 
it  was  successful  even  in  cases  of  confluent  small-pox,  and  that 
when  applied  on  the  first  or  second  day  it  prevented  the  develop- 
ment of  the  eruption,  and  caused  an  abortion  of  the  pustules.  To 
protect  the  skin,  collodion  may  be  applied,  or,  still  better,  the 
flexible  collodion  made  of  collodion,  castor  oil  and  Canada  balsam. 

The  plan  adopted  at  the  Small-pox  Hospital  is  as  follows: 

"  Wait  until  the  pustules  have  discharged,  and  the  discharge  has 
begun  to  dry,  then  put  on  some  of  the  best  olive  oil,  or  a  mixture 
of  one-third  glj'cerin  and  two-thirds  of  rose-water.  Some  of  this 
may  be  applied  once  or  twice  a  day,  for  a  few  days,  until  the 
scabs  begin  to  loosen.  Cold  cream  and  oxide  of  zinc,  or  olive  oil 
and  lime-water,  form  good  applications ;   or  if  the  discharge  is 

*  Formula  15 : 

R.  Tinct.  kramerise, 3y 

Tinct.  opii, "JJxij 

Spt.  chloroform., '"Kxvj 

Syr.  zingib., ^iij 

Aquam  ad ^iv. — M. 

A  taljleppoonl'ul  after  each  action  of  the  bowels.     For  children  five  years  of  age. 

f  Formula  IG : 

Be.  Pnlv  creta?  c.  opio, •     9u 

Tinct.  catechu, 3'j 

Aqnam  menth.  pip.  ad §ij. — M. 

Two  teaspoonfuls  after  each  action  of  the  bowels.     For  children  fis^e  years  of  age. 


VARIOLA   OR  SMALL-POX.  147 

thin  and  excoriating,  calamine  mixed  with  olive  oil.  The  patient 
should  be  warned  not  to  allow  the  scabs  to  dry  and  remain  some 
time  on  the  nose  and  other  parts  of  the  face,  particularly  on  the 
forehead  and  near  the  end  of  the  nose.  AYhen  this  takes  place, 
the  dry  scabs  themselves  leave  deep  marks  in  the  skin,  worse  than 
the  eruption  of  small-pox  itself.  The  pain  of  removing  the  dry 
scabs  is  sometimes  considerable,  and  the  patient  can  hardly  be 
prevailed  to  take  them  off,  or  allow  others  to  do  so.  In  common 
the  pits  from  the  eruption  are  not  deep  at  first,  just  after  the  patient 
has  got  well,  and  we  ma^^  deceive  ourselves  by  thinking  our  efforts 
to  prevent  disfiguration  have  been  attended  with  considerable 
success.  The  disease  leaves  a  peculiar  brown  stain  on  the  skin  at 
first,  which  soon  wears  oflf,  but  the  pitting  is  more  perceptible  a 
twelvemonth  or  so  after  the  patient  has  got  well.*" 

If  ophthalmia  is  severe  two  or  three  leeches  to  the  temples  may 
be  necessary,  and  in  milder  cases  a  solution  of  nitrate  of  silver 
(gr.  j  to  gr.  iv  to  the  oj).  When  the  eyelids  are  swollen  and 
cedematous,  and  the  lips  stick  together  by  a  tenacious  secretion, 
they  should  be  bathed  frequently  with  warm  water  and  a  little 
Ung.  Cetacei,  or  diluted  yellow  oxide  of  mercury  ointment  (Hyd. 
Oxy.  Flava  gr.  viij,  Vaseline  oj)  applied  to  the  edges  of  the  eyelids 
night  and  morning.  When  ulcerations  of  the  cornefe  ensue,  it  has 
been  recommended  to  touch  them  with  a  sharp  point  of  nitrate  of 
silver,  or  a  collyrium  of  sulphate  of  zinc  and  opium  may  be  used.f 
Meigs  and  Pepper  speak  highly  of  a  collyrium  of  borax  and  sul- 
phate of  zinc.:{; 

*  Small-pox,  by  J.  F.  Marson,  Reynolds's  System  of  Medicine,  3d  edit.,  vol.  i,  p.  252. 
t  Formula  17 : 

U.  Zinci  sulph.,  .         .         .         .         .■* gr-  ij 

Vini  opii, n^xx 

Aqiiam  rosae  ad •  SJ  • — M. 

Fiat  collyrium. 
X  Formula  18: 

R .  Sodse  biborat., gr.  xij 

Zinci  sulph., gr.  j 

Aquae  camph., gj 

Aquam  destill.  ad  , 5j. — M. 

Fiat  collyrium. 


148  DISEASES    OF    CHILDEEN. 

CHAPTER    XIII. 

DISEASES    OF    THE    MOUTH    AI^D    FAUCES. 

Stomatitis  and  its  Vaeieties:  Stomatitis  simplex,  or  simple  inflamraation  of  the 
mouth — Symptoms— Causes  and  treatment — Stomatitis  follicularis  (  Vesicular  stomatitis 
— Aphthous  stomatitis) — Symptoms — Causes  and  treatment — Stomatitis  fungosa — Aph- 
thce — Le  Muguet — Thrush  or  white  mouth — Diffuse  inflammation  of  the  mouth — 
Symptoms  and  treatment — Value  of  chlorate  of  potash — Ulcerative  stomatitis — Char- 
acter of  the  ulceration — Local  and  constitutional  causes— Treatment — Chlorate  of 
potash — Bark — Iron — Cod-liver  oil — Local  application  of  nitrate  of  silver — Hydro- 
chloric acid — Gangrenous  stomatitis — Gangrene  of  the  mouth — Canerum  oris — 
Symptoms — Pathology  and  treatment — Caustics — Chlorate  of  potash — Wine — Mercu- 
rial salivation^ Rare  in  children — Treatment — Gingivitis— Acute  tonsillitis— Hyper- 
trophy of  the  tonsils — Simple  pharyngitis — Reti'o-pharyngeal  abscess — Cynanche 
parotidea,  or  mumps. 

INFLAMMATION  of  the  moiith  is  a  troublesome  and  painful  disease 
in  infants  and  3'oung  children.  Although  extremely  common 
during  the  period  of  dentition,  it  may  occur  at  almost  any  age. 
In  one  variety  the  iuHammation  does  not  extend  through  the 
mucous  membrane,  or,  at  the  worst,  it  produces  a  number  of 
♦small,  circular,  irritable  ulcers,  with  a  red  margin  surrounding  a 
depressed  centre,  whilst  in  another  the  ulceration  involves  the 
gums  and  the  mucous  membrane  more  deeply,  and  in  a  third, 
swelling  and  gangrene  attack  the  cheek,  and  destroy  the  life  of 
the  sufferer. 

Stomatitis  simjjiex,  or  inflammation  of  the  mouth,  is  a  mild 
aftection,  causing  trifling  constitutional  disturbance,  and,  except 
under  neglect,  rarely  leading  to  ulceration.  It  is  common  among 
the  infants  and  suckling  children  of  the  poor  during  the  first 
year  of  life,  involving  a  portion,  or  sometimes  nearly  the  whole 
mucous  membrane  of  the  mouth,  particularly  if  the  food  is  taken 
through  bottles  and  the  hygienic  conditions  are  bad.  It  is  rare 
among  the  children  of  the  upper  classes,  unless  the  nipples  of  the 
nurse  are  sore,  or  the  milk  is  faulty.  In  the  out-patient  depart- 
ment of  our  hospitals  it  is  very  frequent.  In  its  mildest  form  it  is 
an  erythema,  but  occasionally  minute  vesicles  are  seen  on  the 
aftected  membrane,  and  the  lips  swell  with  an  herpetic  eruption 
upon  them.  Sometimes  the  salivary  glands  are  very  active,  and 
saliva  dribljles  from  the  mouth.  The  sjmiptoms  are  heat  and  dry- 
ness of  the  mouth,  restlessness  and  feverishness,  flatulence  and 
diarrha-a ;    the  mucous  membrane  presents   patches   of  redness 


DISEASES   OF   THE   MOUTH   AND   FAUCES.  149 

raised  above  the  surrounding  surface,  which  are  seen  on  the  inside 
of  the  cheeks  and  the  angles  of  the  mouth  ;  they  may  also  be 
observed  on  the  hard  palate  and  gnms,  having  a  yellowish  patch 
of  lymph  in  the  centre,  with  a  red^margin. 

The  causes  are  gastro-intestinal  disorder  and  uncleanliness,  and 
eating  indigestible  or  irritating  articles  of  food.  It  is  seen  in 
scarlatina  and  measles,  or  during  dentition,  when  the  gums  are 
irritated  by  the  pressure  of  teeth,  and  then  the  disease  is  local 
instead  of  general.  In  these  cases  the  gums  are  often  red  and 
spongy,  and  bleed  on  being  touched. 

The  disorder  usually  yields  to  a  regulated  diet,  a  dose  of  castor 
oil,  or  a  powder  of  rhubarb  and  carbonate  of  soda.  If  it  does  not 
improve  under  this  treatment,  a  mixture  containing  a  little  mag- 
nesia, or  the  Liq.  Magn.  Carb.  will  be  useful.  Lime-water  should 
be  added  to  the  milk,  and  the  mouth  cleansed  after  each  meal  with 
a  piece  of  soft  rag  dipped  in  warm  water.  If  the  gums  are  swollen 
and  distended  by  the  teeth,  they  should  be  lanced.  Occasionally 
the  disorder  is  kept  up  till  the  nurse  is  changed,  and  the  method  of 
feeding  is  altered.  In  one  well-marked  and  obstinate  case  which 
came  under  my  notice,  the  mouth  did  not  take  on  a  healthy 
appearance  till  feeding  with  a  spoon  was  substituted  for  the  bottle 
and  the  nurse.  I 

Stomatitis  follicularis  [vesicular  stomatitis — aphthous  stomatitis)  is 
common  with  children  during  the  first  dentition.  Large  and 
distinct  pearl-like  vesicles  of  a  round  and  elevated  form  resem- 
bling herpes,  take  place  on  the  inside  of  the  cheeks,  lips,  sides  of 
the  tongue,  and  more  rarely  on  the  gums.  When  they  rupture,  a 
little  glairy  fluid  is  discharged,  leaving  a  round  and  superficial 
ulcer  with  a  red  margin  and  a  yellowish-gray  base.  The  complaint 
arises  from  inflammation  of  the  mucous  follicles,  symptomatic  of 
some  intestinal  disorder  and  acidity  of  the  primce  vife.  It  occurs 
during  teething,  or  after  whooping-cough  or  measles,  in  fact,  it 
may  follow  any  exhausting  complaint.  There  are  several  of  these 
ulcers  which  do  not  usually  run  together,  except  the  disorder  is 
severe;  and  although  most  frequent  on  the  mucous  membrane  of 
the  cheek,  they  are  sometimes  noticeable  on  the  tonsils  and  soft 
palate. 

Symptoms. — ^^The  constitutional  disturbance  is  slight,  and  there 
is  nothing  to  notice  beyond  trifling  feverishness,  loss  of  appetite, 
thirst,  and  irritability  ;  sometimes  there  is  not  even  this  assemblage 


150  DISEASES    OF   CHILDREN. 

of  symptoms,  and  the  chief  feature  is  pain  with  soreness  of  the 
mouth,  which  prevents  the  child  from  taking  nourishment.  The 
complaint  is  of  common  occurrence  in  delicate  children,  and  is 
without  danger.  The  ulcers  pass  away  under  treatment  in  the 
course  of  a  few  days,  but  are  prone  to  recur  from  time  to  time,  as 
in  adults  when  the  digestive  functions  are  deranged.  It  is  im- 
portant to  bear  in  mind  that  the  disease  does  not  always  follow  the 
same  mild  course.  After  the  bursting  of  the  vesicles  the  superficial 
ulceration  that  remains  may  be  coated  with  a  similar  exudation  to 
that  which  occurs  in  thrush,  and  to  be  even  associated  with  the 
formation  of  false  membrane,  as  in  diphtheria.  Such  cases  some- 
times follow  severe  attacks  of  measles. 

Treatment. — An  alterative  dose  of  gray  powder,  soda,  and  rhu- 
barb is  useful,  and  tonics — bark,  with  a  few  grains  of  chlorate  of 
potash — will  bring  about  a  cure.  If  the  mouth  is  very  painful, 
and  prevents  the  child  from  taking  food  or  sucking,  a  weak  solu- 
tion of  nitrate  of  silver  may  be  brushed  over  the  excoriated  parts 
daily,  or  they  may  be  touched  with  a  piece  of  alum  ;  a  lotion  con- 
sisting of  one  ounce  of  glycerin  of  borax  to  five  ounces  of  water 
is  also  a  simple  and  useful  application. 

Stomatitis Fmigosa — AphtJue  {  Underwood  and  Deioees) — Le  lluguet 
{French) — Thrush  or  White  Mouth — Diffuse  Inflammation  of  the 
Mouth. — -Tliis  complaint  is  met  with  at  all  ages,  but  it  is  most  com- 
mon in  infants  and  young  children,  as  the  result  of  improper  or 
artificial  feeding.  The  mouth  is  hot  and  dry,  and  the  salivary 
secretion  is  diminished.  Small  white  conical  patches  form  on  the 
inside  of  the  cheeks,  angles  of  the  mouth,  and  sides  of  the  tongue. 
After  two  or  three  days  these  elevated  patches  present  a  curdy  or 
soft  cheesy  exudation  of  false  membrane,  and  may  be  seen  on  the 
pharynx,  tonsils,  or  hard  palate,  and  if  removed  the  surface  bleeds 
until  it  is  covered  by  fresh  exudation.  The  patches  assume  a  gray- 
ish ragged  appearance,  leaving  an  unbroken  smooth  surface,  or  a 
superficial  excoriation,  which  increases  the  difficulty  of  swallowing 
and  sucking.  The  disease  may  extend  into  the  oesophagus  or  the 
air-passages,  and  cause  cough  and  expectoration,  which  reduces 
the  child's  strength,  and  may  end  in  exhaustion  and  inanition.  It 
is  most  frequent  in  infants  of  two  or  three  months  old.  The  con- 
stitutional symptoms  are  gastric  disorder  and  diarrhoea,  with  all 
the  symptoms  of  muco-enteritis;  the  motions  are  greenish,  mixed 
with  curdy  masses  of  milk,  and  in  this  way-  the  disease  extends 


DISEASES   OF   THE   MOUTH   AND   FAUCES.  151 

through  the  whole  alimentary  tract.  The  amis  is  often  red  and 
excoriated  from  the  acrid  nature  of  the  howel  discharges,  and 
there  is  erythema  of  the  buttocks  and  perinseuni  of  the  child,  and 
if  of  the  male  sex,  the  scrotum  is  sore,  excoriated,  and  inflamed. 
Febrile  excitement  is  not  uncommon,  and  the  pulse  is  accelerated. 
It  occurs  in  delicate  children  who  are  badly  fed  and  clothed,  and 
is  looked  upon  as  a  serious  sign ;  but  it  is  simply  the  local  indica- 
tion of  a  feeble  constitutional  condition.  It  comes  and  goes,  and 
when  seen  as  the  accompaniment  of  acute  or  long-standing 
chronic  disease,  is  of  evil  augury.  The  exudation  has  been  seen 
in  the  stomach  in  Peyer's  patches,  and  in  the  CEecum.  "  Under 
the  microscope  the  curdy  exudation  of  thrush  has  been  found  to 
consist  of  thickened  epithelium  cells,  mingled  with  numerous 
minute  cryptogamic  sporules  or  seeds,  from  the  midst  of  clusters 
of  which,  long  threadlike,  jointed,  and  branching  plants  arise, 
intertwining  with  one  another.  It  was  discovered  by  Berg,  of 
Stockholm,  and  Grubz,  of  Vienna,  at  the  same  time,  and  has  been 
named  the  Oidium  albicans.''*- 

Like  the  former  variety,  it  is  chiefly  met  with  among  the  chil- 
dren of  the  poor,  and  those  brought  up  by  hand  or  suckled  too 
long. 

The  predisposing  causes  are  attributable  to  general  or  local  dis- 
ease, but  the  exciting  cause  is  owing  to  a  parasitic  fungus,  as  we 
have  just  seen  in  the  mucous  membrane.  This  vegetation  is  proba- 
bly derived  from  some  mouldy  article  of  diet,  which  may  spread 
and  be  conveyed  to  the  nurse's  nipple,  and  from  the  latter  to  the 
child's  mouth. 

Treatment. — In  most  cases  a  dose  of  castor  oil  and  a  proper  regu- 
lation of  the  diet  will  be  all  that  is  needed  ;  but  in  every  case  I 
would  recommend  the  chlorate  of  potash,  which  is  a  specific  ;  and 
a  few  grains  administered  three  times  a  day  will  have  a  marvellous 
effect  in  curing  the  disorder.  The  mouth  should  be  washed  out 
after  each  meal,  and  a  local  application  of  the  glj^cerin  of  borax 
be  employed ;  or  the  affected  part  may  be  brushed  over  with  a 
solution  of  nitrate  of  silver  (gr.  v  ad  fsj).  Sir  William  Jenuer 
recommends  a  solution  of  sulphite  of  soda  (5j  ad  f.^j),  from  the 
destructive  influence  which  the  sulphurous  acid  has  on  the  fungus. 

Ulcerative  Stomatitis  [Ulcero-membranous  stomatitis.,  Rilliet  and 
Barthez)  is  a  mild  and  frequent  disorder,  but  in  no  way  dangerous 

*  Reynolds's  System  of  Medicine,  Art.  Thrush,  vol.  iii,  p.  8. 


152  DISEASES   OF   CHILDREN. 

to  life.  It  is  more  frequent  in  hospital  tlian  in  private  practice. 
It  would  seem  to  be  an  aggravated  form  of  the  membranous  affec- 
tion, which  either  advances  to  ulceration,  or  in  milder  cases  is 
absorbed  without  proceeding  any  further.  The  affected  mem- 
brane in  the  first  instance  is  white  or  dirty  gray,  or  black,  and 
the  surrounding  membrane  swollen  and  inflamed.  The  plastic 
exudation  is  thick,  and  is  more  or  less  adherent  to  the  tissue 
"beneath,  and,  if  raised,  exposes  a  superficial  bleeding  ulcer.  Even 
when  the  exudation  is  gently  removed  blood  oozes  from  the  ex- 
posed surface.  The  affection  is  seen  to  occupy  the  inside  of  the 
cheek,  and  to  extend  to  the  gums  of  the  front  teeth,  which  are 
swollen  and  sjDongy,  bleeding  on  the  slightest  touch,  and,  by  their 
retraction,  causing  the  teeth  to  become  loose  in  their  sockets.  The 
cheek  and  lips  in  contact  with  the  affected  parts  likewise  become 
the  seat  of  irregular  ulceration,  which  may  prove  very  obstinate, 
or  degenerate  into  a  more  severe  form.  In  mild  and  favorable 
cases,  the  ulcers  being  superficial  rapidly  diminish  in  size  and  heal 
quickl}^,  the  saliva  becomes  less  in  quantity,  and  the  gums  take  on  a 
healthy  appearance.  But  in  some  cases  the  ulcers  destroy  the  gum, 
and  extend  deeplj^  and  are  very  intractable  to  treatment.  They 
may  involve  the  whole  mucous  membrane  of  the  mouth,  running 
together  and  extending  to  the  hard  palate ;  and  when  the  disease 
is  so  general,  the  submaxillary  glands  are  hard,  swollen,  and  pain- 
ful. The  breath  is  offensive,  and  the  salivary  secretion  is  increased. 
The  subjects  of  this  complaint  are  delicate  children,  who  have 
been  badly  fed  and  cared  for.  It  is  common  between  the  ages  of 
five  and  ten  years,  and  it  often  prevails  as  an  epidemic.  The 
scrofulous  children  of  the  poor  are  frequent  victims,  particularly 
if  their  health  has  been  further  reduced  by  eruptive  diseases  or 
pneumonia,  or  if  they  possess  bad  teeth.  In  one  case  under  my 
care  there  was  an  obstinate  irregular  ulcer  on  the  gum,  which  had 
receded  from  a  carious  tooth,  and  it  resisted  all  remedies  till  the 
decayed  stump  was  removed,  when  it  took  on  healthy  action. 
There  is  generally  some  febrile  disturbance,  which  continues  for  a 
day  or  two. 

In  the  case  of  a  female  child,  nine  months  old,  who  was  shown 
to  me  in  May,  1877,  by  Dr.  Wynn  Williams,  the  ulceration  occupied 
the  inside  of  the  lower  lip  in  three  distinct  patches,  the  largest 
being  the  size  of  a  threepenny  piece.  The  ulceration  was  not  deep 
nor  surrounded  by  induration  of  the  mucous  membrane,  which 


DISEASES   OF   THE   MOUTH   AND    FAUCES.  153 

presented  no  variation  from  the  tint  of  health.  There  sprang  up 
from  the  base  of  the  ulcerated  surface  long  whitish  points,  like 
the  fungoid  excrescences  of  an  open  wart.  When  first  seen  by  Dr. 
Williams  the  affected  part  presented  a  pealike  hard  body,  feeling 
like  a  wart.  The  child  was  suffering  from  bronchopneumonia, 
chiefly  of  the  right  lung,  of  one  week's  duration,  and  the  lip  be- 
came affected  on  the  third  day  of  the  attack.  The  face  was  pallid, 
and  the  lips  dusky  and  separated,  the  respiration  was  short  and 
p.hallow,  60  per  minute;  the  morning  temperature  103°,  the  pulse 
112;  in  the  evening  the  temperature  reached  104.2°,  and  the  pulse 
120.  There  was  no  ulceration  in  any  other  part  of  the  mouth,  nor 
any  aphthous  exudation. 

When  the  exanthematous  fevers  have  altered  the  qualit}'-  of  the 
blood,  or  a  young  child  is  struck  down  by  some  acute  disease  with 
a  high  temperature,  the  mucous  membranes  are  prone  to  sufier, 
and  especially  the  mouth. 

Treatment. — This  consists  in  attention  to  the  general  health  ;  the 
diet  should  be  regulated  and  the  digestive  functions  attended  to. 
In  the  shape  of  medicine  the  chlorate  of  potash  is  a  specific  here, 
as  in  other  varieties  of  ulceration  of  the  mouth  in  children.  A 
grain  three  or  four  times  a  day  in  water  for  a  child  a  year  old, 
and  one  additional  grain  for  every  year  of  the  child's  age  up  to 
ten  grains  will  be  a  suitable  dose.  A  drop  or  two  of  the  dilute 
hydrochloric  acid,  and  the  addition  of  the  tincture  of  cinchona,  or 
the  ammonio-citrate  of  iron  will  soon  bring  about  a  cure  in  ordi- 
nary cases.  Cod-liver  oil,  quinine,  and  the  syrup  of  the  iodide  of 
iron  will  be  useful.  If  the  ulceration  is  obstinate,  the  application 
of  a  solution  of  nitrate  of  silver  to  the  ulcer,  or  the  hydrochloric 
acid  is  desirable.  I  have  often  known  the  gums  to  take  on  healthy 
action  at  once  after  an  application  of  nitrate  of  silver  (gr.  v  ad 
5j),  and  to  be  well  in  a  week  when  chlorate  of  potash  has  been 
given  at  the  same  time.  As  in  the  sore  throat  of  scarlatina,  brush- 
ing over  the  affected  part  with  the  tincture  of  iron  and  glycerin  is 
a  good  application. 

Gangrenous  Stomatitis  {Cancrum  oris). — This  is  a  serious  and 
rare*  constitutional  affection,  attacking  children  whose  blood  is 

*  "  I  have  only  seven  times  had  the  opportunity  of  witnessing  it ;  but  so  fatal,  that 
in  six  out  of  these  seven  cases  the  patients  died.  The  larger  experience  of  other  ob- 
servers shows  an  equally  unfavorable  result,  since  20  out  of  21  cases  that  came  under 
the  notice  of  MM.  Killiet  and  Barthez  had  a  fatal  termination,  and  a  recent  French 


154  DISEASES   OF   CHILDRElvr. 

deranged,  and  is  a  far  more  important  disease  than  any  of  the 
varieties  we  have  hitherto  considered.  It  may  follow  the  eruptive 
fevers  (particularly  measles),  typhoid  fever,  and  tuberculosis. 

"  In  by  far  the  majority  of  cases  it  succeeds  to  some  acute  illness, 
by  which  the  health  of  the  child  has  been  greatly  undermined.  The 
disease  of  all  others  which  seems  most  to  predispose  to  this  affec- 
tion is  measles.  Of  ninety-eight  cases  collected  by  M.  Tourdes,  in 
forty-one,  or  nearly  half  the  cases,  it  followed  measles.  In  nine, 
it  followed  intermittent  fever ;  in  nine,  typhoid  ;  in  seven,  it  is  put 
down  as  due  to  calomel ;  in  six,  it  followed  pertussis  ;  in  five,  scarlet 
fever;  in  five,  enteritis;  and  the  remaining  followed  various  dis- 
eases. Again,  of  forty-six  cases  collected  by  MM.  Boulez  and 
Caillault,  in  thirty-eight  it  followed  attacks  of  measles."*  Most 
authorities  agree  that  the  disease  is  most  often  seen  between  two 
and  five  years,  but  it  may  occur  to  any  children  up  to  twelve  or 
thirteen.  Like  the  former  disease,  it  is  more  frequent  in  hospital 
than  in  private  practice.  The  disease  is  regarded  by  most  ob- 
servers as  beginning  in  the  mucous  membrane  .of  the  mouth,  with 
the  formation  of  thick  yellow  patches  of  membrane,  which  termi- 
nate in  ulceration.  A  hard  swelling  also  forms,  surrounded  by  a 
tense  infiltration  of  the  cellular  tissue  of  the  cheek.  The  symp- 
toms begin  with  fetor  of  the  breath,  and  a  discharge  of  saliva ; 
the  inside  of  the  cheek  is  tense,  hard,  red,  and  shining,  and  it  is 
usually  limited  to  one  side.  In  the  centre  is  a  bright-red  spot, 
and  the  mouth  is  opened  with  difficulty.  An  irregular  excavated 
ulcer  forms,  which  is  covered  with  an  ashy  loose  slough.  The 
teeth  become  loose,  and  occasionally  drop  out,  whilst  the  alveoli 
are  laid  bare,  and  sometimes  become  necrosed.  As  the  disease 
advances,  the  swelling  of  the  cheek  increases,  an(i  the  central  spot 
becomes  a  gangrenous  eschar  or  slough,  and  blackened  shreds  of 
tissue  are  cast  off".  The  disease  is  usually  limited  to  one  side  of 
the  mouth. 

Treatment. — The  only  reliable  means  of  cure  consists  in  the  ap- 
plication of  strong  hydrochloric  acid,  or  nitric  acid,  and  it  is 
obvious  that  if  such  a  remedy  is  to  be  of  service,  it  must  be  active 

writer  (Tourdes,  Du  Noma,  etc.,  4to,  Tli&se  de  Strasbourg,  1848)  wlio  has  collected 
from  different  sources  239  cases,  which  did  not  all  occur  in  children,  states  that  176  of 
the  number,  or  75  per  qent.,  terminated  fatally." — Wesfs  Diseases  of  Infancy  and  Child- 
hood, 4tli  edition,  p.  532. 

*  Keynolds's  System  of  Medicine,  Art.  Gangrenous  Stomatitis,  vol.  iii,  p.  17. 


DISEASES   OF   THE   MOUTH   AND   FAUCES.  155 

and  applied  tliorouglily  whilst  the  patient  is  under  the  influence  of 
chloroform.  It  may  be  necessary  to  repeat  the  application  from 
time  to  time,  and  the  mouth  must  be  washed  frequently  with 
Condy's  fluid,  or  a  weak  solution  of  chloride  of  soda.  If  the  cheek 
is  tender  on  the  outside,  a  poultice  or  fomentation  will  be  advis- 
able. Castor  oil,  chlorate  of  potash,  iron,  etc.,  will  be  needed 
(Form.  9,  10). 

Mercurial  Salivation. — Merciirj-,  when  injudiciously^  administered, 
may  produce  ulceration  of  the  gums,  loss  of  teeth,  fetor  of  the 
breath,  and  salivation,  leading  to  the  various  forms  of  stomatitis 
and  gangrene  of  the  mouth  ;  but  such  cases  are  very  rare,  and  we 
look  for  the  influence  of  the  drug  in  the  greenish  stools  of  infants, 
rather  than  in  the  excessive  action  of  the  salivary  glands.*  In 
addition  to  these  symptoms  there  may  be  swelling  of  the  sub- 
maxillary glands  and  superficial  ulceration  upon  the  gums,  which 
may  extend  to  the  cheeks  and  tongue,  giving  rise  to  an  ulcerous 
or  gangrenous  form  of  stomatitis.  The  constitution  sympathizes 
in  the  irritative  febrile  disturbance,  and  weeks  may  elapse  before 
the  afi:ected  parts  resume  a  healthy  state.  Children  so  afl:'ected  lose 
flesh  and  strength,  and  are  peevish  and  irritable.  They  are  dis- 
inclined to  take  nourishment  if  the  mouth  is  sore  and  painful,  and 
that  which  is  swallowed  is  imperfectly  assimilated  from  the  quan- 
tity of  altered  saliva  which  finds  its  way  into  the  stomach. 
'•Nearly  30,000  children  of  all  ages  have  come  ander  my  care 
during  my  connection  with  the  Children's  Infirmary  and  the  Chil- 
dren's Hospital,  and  I  have  administered  mercury  to  any  of  them 
who  seemed  to  require  it,  but  hardly  ever  saw  salivation  follow  its 
employment  before  the  completion  of  the  first  dentition ;  and 
never  observed  that  medicine,  at  any  age,  produced  any  afl:ection 
of  the  mouth  sufliciently  serious  to  cause  me  a  moment's  anxiety."t 
When  given  in  a  single  or  moderate  dose  it  would  appear  to  be 
eliminated  by  all  the  secretions,  and  not  a  trace  can  be  detected  in 
any  organs  or  tissues.  When,  however,  it  is  continued  recklessly 
or  intentionally  for  days  together,  the  power  of  elimination  gradu- 

*  In  some  cases  of  ptyalism,  the  parotid  and  salivary  glands  are  said  to  be  swelled 
and  hypersemic,  and  the  fluid  dribbling  from  the  months  of  cliildren  may  reach  many 
ounces  in  twenty-four  hours.  In  adults  it  has  been  estimated  in  severe  cases  at  seven 
or  eight  pounds.  "  Lehniann  and  other  observers  have  found  it  at  iirst  more  mucous, 
cloudy,  of  greater  spej:ific  gravity,  and  richer  in  solid  constituents  (young  and  old  epi- 
thelial cells)  than  normal  saliva." — JSfiemeyer^s  Practical  Medicine,  vol.  i,  p.  443. 

t  West's  Diseases  of  Infancy  and  Childhood,  4th  edition,  p.  539. 


156  DISEASES    OF    CHILDREN. 

ally  fails,  and  it  accuninlates  in  the  body,  lessening  the  amount 
of  fibrin  in  the  blood,  and  increasing  the  activity  of  all  the 
glandular  organs.  "  The  chief  channel  of  escape  seems  to  be  the 
kidnej'S,  but  it  is  very  certain  that,  at  least  in  some  cases,  the 
drug  is  freely  excreted  by  the  salivary  glands  as  well  as  by  the 
intestines."* 

Chlorate  of  potash  and  sulphate  of  magnesia  are  both  useful 
remedies,  the  former  acting  upon  the  mucous  membrane  of  the 
mouth,  and  the  latter  stimulating  the  action  of  the  bowels.  For 
the  soreness  of  the  mouth,  a  solution  of  nitrate  of  silver  (gr.  v 
ad  fi^j)  should  be  applied  twice  a  day,  and  every  time  after  taking 
food,  which  should  consist  chiefly  of  milk;  the  parts  affected 
should  be  gently  wiped  with  a  piece  of  soft  rag  dipped  in  the 
lotion  of  borax  before  mentioned.  The  employment  of  sedatives 
may  be  required  to  allay  pain  and  procure  sleep. 

Gingivitis — Inflammation  of  the  Gums — Disorders  Accom-panying 
Dentition. — Dentition  in  most  healthy  children  is  attended  with 
redness,  heat,  and  swelling  of  the  gums,  whichare  also  tender,  and 
there  is  dryness  of  the  mouth  in  some  cases,  but  often  a  free  flow 
of  saliva.  There  is  pain  in  suckling,  when  the  child  attempts  to 
grasp  the  nipple,  which  it  speedily  releases,  and  cries,  and  is  fret- 
ful. When  children  are  strong  and  full  of  flesh  there  is  consider- 
able disturbance  of  the  system,  and  the  cutting  of  each  tooth  is 
attended  with  heat  and  flushing  of  the  face,  sleeplessness,  and 
fever.  Cerebral  disturbance,  and  even  inflammation  or  convul- 
sions, are  occasionally  observed  ;  skin  diseases  and  eruptions  about 
the  scalp  are  common.  In  rickety  children  dentition  is  retarded, 
and  there  is  no  derangement  worthy  of  notice.  Some  children  pass 
through  dentition  with  little,  if  any,  constitutional  disturbance, 
one  tooth  after  another  appearing  in  regular  succession,  without 
pain  or  irritation  of  any  kind.  But  it  is  not  so  in  every  case ; 
there  are  many  instances  in  which  dentition  is  painful,  and  every 
new  tooth  either  provokes  a  short  attack  of  inflammatory  fever, 
diarrhoea,  salivation,  or  even  a  convulsion.  The  gums  are  red, 
hot,  and  swollen,  and  the  child  is  perpetually  putting  the  fingers 
in  the  mouth,  and  is  unable  to  suck  and  grasp  the  nipple  ;  aphthous 
ulceration  takes  place,  the  child  is  feverish,  cannot  sleep,  and  is 
extremel}^  restless  and  fretful ;  sometimes  laryngismus  or  inflam- 
mation of  the  air-passages  (bronchitis  or  pneumonia)  springs  up, 

*  Treatise  on  Therapeutics,  by  H.  C.  Wood,  M.D.,  1876,  p.  368. 


DISEASES    OF    THE    MOUTH    AND    FAUCES.  157 

or  cutaneous  eruptions,  as  lichen  or  strophulus.  In  some  children 
the  fretfuluess  and  disturbed  sleep  are  very  trying  to  the  parents, 
and  not  without  anxiety  to  the  medical  attendant ;  the  child 
grows  pale  and  fractious,  though  the  gums  have  been  lanced  and 
the  teeth  are  appearing.  It  sleeps  for  a  short  time,  then  wakes 
up  flushed  and  excited,  and  cannot  rest  again.  The  child  is  un- 
easy, and  puts  the  fingers  to  the  mouth,  cries  at  any  sudden  noise, 
and  will  not  leave  the  nurse's  arms.  The  nervous  excitability  is 
great,  and  unless  the  child  gets  rest,  it  grows  pallid  and  exhaust- 
ed, refusing  food,  and  often  vomiting  the  little  that  is  taken,  the 
hands  and  head  are  hot,  the  pulse  is  quick,  and  the  temperature 
elevated. 

Treatment. — In  ordinary  cases  a  simple  aperient,  and  rubbing 
the  gums  to  and  fro  with  a  piece  of  w^hite  sugar  will  suffice ;  but 
if  the  gum  is  tense  and  painful,  and  the  tooth  distends  it,  a  free 
incision  will  give  immediate  relief.  The  lancet  should  be  made  to 
incise  the  gum  in  the  direction  of  the  alveolar  process,  although  a 
second  and  shorter  transverse  incision  is  sometimes  advisable.  If 
the  child  is  strong,  a  grain  of  calomel,  and  a  saline  niixture  (Form. 
8)  will  be  necessary  to  open  the  bowels  and  remove  any  intestinal 
disturbance.  If  in  spite  of  the  gums  being  freely  incised,  and  the 
mouth  moist,  the  nervous  irritation  and  sleeplessness  continue,  and 
the  nurse  and  attendants  are  worn  out  with  the  restlessness  of  the 
child,  sleep  must  be  procured,  and  the  nervous  irritation  allayed. 
For  this  purpose,  a  mixture  of  bromide  of  potassium  and  hydrate 
of  chloral  is  advisable  at  bedtime,  and  it  should  be  repeated  if 
tranquil  sleep  does  not  ensue,  while  the  bromide  may  be  given 
during  the  day. 

Tonsillitis — Cynanche  Tonsillaris — Quinsy — Causes — Symptoms — 
Treatment.^ — This  disease  sets  in  with  rigors  and  febrile  symp- 
toms, pain  in  the  head,  limbs, and  back,  to  which  succeed  heat  and 
dryness  in  the  throat.  Any  attempt  at  swallowing  is  extremely 
painful,  and  the  patient  feels  as  though  there  was  a  lump  in  the 
throat.  The  voice  is  thick  and  guttural,  and  the  tongue  is  covered 
with  a  creamy  fur.  The  pharjnix  presents  a  deep  reddish  tint, 
and  one  tonsil  is  noticed  to  be  more  swollen  than  the  other,  the 
disease  being  usually  limited  to  one  side;  a  patch  of  lymph  is 
seen  coating  the  aifected  tonsil,  and  the  act  of  swallowing  causes 

*  The  diagnosis  from  the  throat  affection  of  diphtheria  and  scarlet  fever  is  considered 
in  their  respective  chapters. 


158  DISEASES    OF    CHILDREX. 

a  darting  pain  through  the  ear  on  the  affected  side,  and  throbbing; 
there  is  a  free  discharge  of  saliva,  and  liquids  return  through  the 
nose.  The  neck  below  the  ramus  of  the  jaw  is  tender  and  swollen 
in  some  cases,  and  as  the  complaint  progresses  the  inflammatory 
fever  increases,  till  the  stage  of  suppuration  is  reached,  which  or- 
dinarily happens  in  Ave  or  six  days.  The  disease  may  end  in  reso- 
lution, the  inflammation  and  infiltration  of  the  afi:ected  tissues 
gradually  subsiding,  or  it  may  go  on  to  suppuration,  leaving  a 
deep,  ragged,  excavated  ulcer,  or  it  may  terminate  in  chronic  in- 
flammation and  enlargement.  When  suppuration  takes  place 
there  is  fluctuation,  but  the  tonsil  maj^  be  infiltrated  with  blood 
and  serum,  and  the  palate  be  much  swollen  without  the  formation 
of  any  pus. 

Delicate  children  are  occasionally  liable  to  the  complaint  from 
cold  and  exposure  to  draughts  of  air  when  the  body  is  heated,  as 
when  coming  out  of  a  hot  and  close  room  * 

Treatment. — If  there  is  much  tenderness  below  the  jaws,  and 
the  little  patient  feels  pain  in  separating  them,  two  or  three  leeches 
will  be  useful,  and  a  poultice  applied  afterwards.  At  an  early 
period,  before  any  matter  has  formed,  a  few  punctures  with  a 
bistoury  guarded  with  a  piece  of  lint  will  relieve  the  tension,  and 
drain  the  infiltrated  tissues;  the  mouth  must  be  continually 
washed  out  with  warm  water.  At  an  early  period,  if  there  is 
much  febrile  excitement,  a  diaphoretic  containing  antimony  (Form. 
7)  or  aconite  should  be  given. 

In  some  inflammatory  affections  of  the  throat  in  children,  as  in 
tonsillitis  and  general  pharyngitis,  half  a  minim  of  the  tincture  of 
aconite  may  be  given  to  a  child  in  a  teaspoonful  of  water  every 
hour,  or  even  half  hour,  with  great  advantage.  But  its  effects 
must  be  watched  lest  it  should  depress  the  circulation  too  much, 
or  render  the  pulse  unsteady.  The  remedy  will  generally  convert 
the  dry  and  hot  skin  into  a  sweating  one,  and  control  the  febrile 
excitement  and  restlessness  ;  the  pulse  loses  its  hardness,  and  falls 
in  frequency,  the  temperature  is  reduced,  and  relief  follows  in  a 
short  time.     The  tonsils  become  less  swollen  and  congested,  and 


*  Of  1000  cases  of  tonsillitis  treated  by  Dr.  Morell  Mackenzie  at  the  Hospital  for 
Diseases  of  the  Throat,  there  were  only  3G  oases  from  10  to  15  years  of  age,  and  184 
from  15  to  20.  The  most  common  period  is  between  20  and  30;  after  25  there  is  a 
remarkable  fall.  Young  ciiildren  are  very  little  subject  to  the  disease,  and  before  the 
age  of  five  it  is  seldom  seen  (Diseases  of  llie  Throat  and  Nose,  ISSO,  p.  49). 


DISEASES   or   THE   MOUTH   AND   FAUCES.  159 

the  mucous  membrane  of  the  throat  more  moist  and  natural.  "If 
caught  at  the  commencement,  a  quinsy  or  sore  throat  rarelj''  fails 
to  succumb  in  twentj'-four  to  forty-eight  hours."*  Guaiacum  is 
another  remedy  which  has  long  enjoyed  a  great  repute  in  the 
treatment  of  this  affection.  Dr.  Morel!  Mackenzie  thinks  it  far 
superior  to  aconite.  It  may  be  given  in  the  form  of  powder,  four 
or  five  grains  in  a  little  jam,  every  six  hours,  or  the  Trochisci 
Guaiaci  of  the  Throat  HosjDital  Pharmacopoeia  may  be  ordered. f 

A  grain  or  two  of  calomel  to  stir  up  the  functions  of  the  liver 
will  abate  the  headache.  The  patient  must  be  fed  with  milk  and 
soda-water,  tea,  lemonade,  and  thin  water  arrowroot,  the  tartrate 
of  potash  drink  to  keep  the  bowels  free,  and  beef  tea  to  support 
the  strength.  Tonsillitis  is  soon  succeeded  by  prostration,  and 
quinine  and  other  tonics  may  be  called  for  at  an  early  stage  of  the 
aftection. 

Hypertrophy  of  the  tonsils  may  follow  acute  tonsillitis,  but  more 
commonly  it  is  seen  in  delicate  children  who  are  anasmic,  rickety, 
or  strumous,  or  afflicted  with  a  syphilitic  taint.  The  disease 
begins  as  a  chronic  affection  during  the  first  two  or  three  years 
of  life.:|:  The  tonsils  project  in  the  middle  line  of  the  fauces, 
narrowing  the  aperture,  and  interfering  with  swallowing  and 
speaking.  Children  so  afiected  sleep  heavily  at  night,  with  the 
mouth  open,  and  are  restless.  They  are  liable  to  catarrhal  attacks 
and  deafness.  If  they  are  young,  and  the  tonsils  do  not  meet, 
local  treatment  by  nitrate  of  silver  and  perchloride  of  iron  may 
keep  the  disease  in  check.  As  the  age  advances,  and  the  general 
health  improves,  the  enlargement  under  treatment  subsides,  but 
in  too  many  cases  excision  of  a  portion  of  the  enlarged  glands 
must  be  resorted  to.  Cup-shaped  depressions  in  the  lower  part  of 
the  chest-wall  are  frequently  observed  in  children  suffering  from 
enlarged  tonsils,  when  they  nearly  meet,  and  narrow  the  entrance 
for  the  admission  of  air  to  the  lungs.  These  depressions,  due  to 
imperfect  expansion  of  the  lungs,  disappear  after  excision  of  the 
tonsils,  by  permitting  a  freer  entrance  of  air  to  the  imperfectly 

*  Handbook  of  Therapeutics,  by  S.  Ringer,  M.D.,  8th  edit.,  p.  441.  For  fuller  infor- 
mation on  the  action  of  aconite,  see  Chap.  XI,  On  Scarlatina. 

t  A  Manual  of  Diseases  of  the  Throat  and  Nose,  vol.  i,  p.  57,  1880. 

X  Of  1000  cases,  Dr.  Morell  Mackenzie  met  with  265  under  the  age  of  10  years,  and 
of  these  84  occurred  from  1  to  5,  and  181  from  5  to  10  (op.  cit.,  p  61). 


160  DISEASES    OF    CHILDEEX. 

expanded  vesicles.*  The  -well-known  pigeon-breast  sometimes 
arises  from  chronic  enlargement  of  the  tonsils. 

Simple  'pharyngitis,  or  inflammatory  sore  throat,  is  an  affection 
of  the  tonsils,  soft  palate,  and  pharynx,  unaccompanied  by  ulcera- 
tion or  exudation,  and  is  common  among  children  during  cold  and 
changeable  weather.  It  is  either  a  simple  idiopathic  affection,  or 
it  occurs  as  the  accompaniment  of  measles,  scarlet  fever,  bronchitis, 
pneumonia,  croup,  and  laryngitis.  It  is  much  oftener  a  secondary 
than  a  primary  disease.  The  mucous  membrane  of  the  parts  just 
alluded  to  is  swollen  and  slightly  red,  and  a  mucous  or  sero-puru- 
lent  secretion  is  seen  upon  them,  particularly  the  back  of  the 
pharynx,  which  has  a  red,  roughened,  and  granular  appearance. 
The  mucous  membrane  in  the  secondary  affection  is  often  dnsky 
and  purple,  and  the  tonsils  are  more  swollen  than  when  the  com- 
plaint is  idiopathic,  and  arises  from  cold  and  exposure,  or  from 
swallowing  boiling  liquids. 

Symptoms. — The  complaint  begins  with  disturbed  sleep  and 
restlessness ;  there  is  febrile  excitement,  as  heat  of  skin,  flushed 
face,  headache,  thirst,  tenderness  over  the  pharynx,  and  diflnculty 
in  swallowing.  The  appetite  is  gone,  and  the  child  refuses  to  take 
food.  The  pulse  and  respiration  may  be  increased  in  frequency, 
and  the  temperature  reach  100°  or  more.  In  very  young  children 
there  is  often  croupy  cough  and  bronchial  irritation.  In  one  case 
under  my  care  the  tracheal  irritation  was  certainly  secondary  to 
the  pharyngeal  aftec'tion,  and  it  travelled  down  into  the  bronchi 
and  produced  suftbcative  bronchitis  and  death.  The  disease  is 
not  dangerous  in  itself,  but  from  the  complications  to  which  it 
may  give  rise. 

The  treatment  consists  in  applying  a  piece  of  linen  rag  (twice 
folded)  dipped  in  tepid  water  to  the  throat  under  a  piece  of  oiled 
silk.  If  this  does  not  give  comfort,  and  there  should  be  swelling 
and  irritation  of  the  cervical  glands,  a  warm  linseed  poultice  is  the 
best  application.  In  young  children  I  have  occasionally  mopped 
out  the  phar^nix  twice  a  day  with  a  solution  of  nitrate  of  silver 
(gr.  V  ad  f,5J),  and  seen  great  advantage  follow  it  when  the  disease 
has  not  invaded  the  trachea.  In  recent  and  acute  cases,  the  tem- 
perature of  the  apartment  should  be  warm,  and  the  atmosphere 
moist.    Milk  and  water,  weak  tea,  and  mucilaginous  drinks  should 

*  Two  Observations  on  Children,  by  Norman  Moore,  M.D.,  St.  Bartholomew's  Hos- 
pital Reports,  1874,  vol.  x,  \).  130. 


DISEASES   OF   THE   MOUTH   AND    FAUCES.  161 

be  given  as  a  diet.  A  refrigerant  and  saline  aperient  is  usually 
needed  (Form.  8),  and  diaphoretics  and  mild  sedatives  of  various 
kinds  are  useful  (Forms.  7, 12,  7(3)  to  calm  excitement,  subdue  irri- 
tation, and  determine  to  the  skin. 

Retropharyngeal  abscess  consists  in  the  formation  of  matter  be- 
tween the  vertebral  column  and  the  posterior  wall  of  the  pharynx  ; 
it  is  most  frequent  in  infancy  and  early  life.  Children  of  a  stru- 
mous or  tubercular  constitution  are  most  liable  to  the  complaint, 
and  caries  of  the  cervical  vertebros,  or  inflammation  of  the  sub- 
mucous areolar  tissue  may  provoke  the  disease. 

"The  cause  is  mentioned  in  twenty  cases  of  the  primary  form, 
collated  by  Dr.  Allin,  as  follows:  Exposure  to  cold,  ten  cases; 
lodgment  of  bone  in  pharynx,  eight  cases ;  blow  with  a  fencing 
foil,  one  case.  In  the  last  case,  the  button  of  a  fencing  foil  passed 
through  the  right  nostril  into  the  pharynx."*  Sometimes  no 
cause  can  be  ascertained. 

Many  writers  describe  the  disease  as  secondary  when  it  follows 
the  eruptive  fevers,  as  measles  and  scarlatina,  the  inflammatory 
state  of  the  pharynx  involving  the  cellular  tissue  beneath,  and 
leading  to  suppuration.  It  is  then  regarded  as  of  idiopathic  origin. 
"When  thus  occurring,  it  is  similar,  both  as  regards  cause  and 
nature,  to  lumbar  abscess.  In  a  few  recorded  cases  the  abscess  has 
been  a  sequel  to  erysipelas."  (Lewis  Smith.)  It  has  also  been 
traced  to  inflammation  of  the  lymphatic  glands,  between  the 
pharynx  and  vertebrae.  (Fleming.) 

Symptoms. — The  disease  generally  sets  in  with  fever  and  restless- 
ness, furred  tongue,  heat  of  mouth,  difl&culty  in  deglutition,  and 
the  impossibility  of  assuming  a  recumbent  posture.  There  is  also 
in  some  cases  a  stifl:hess  of  the  neck,  and  pain  in  moving  the  head. 
As  the  complaint  advances  the  respiration  becomes  labored,  and 
food  cannot  be  swallowed  without  pain.  Occasionally  there  is 
croupy  cough.  The  early  symptoms  in  a  strumous-looking  child, 
two  years  of  age,  which  came  under  the  care  of  Dr.  Oxley,  at  the 
Liverpool  Infirmary  for  Children,  were  stifltness  of  the  neck, 
labored  breathing,  and  a  croupy  sound  on  inspiration,  but  the 
little  patient  was  able  to  swallow  and  cry.  Eleven  days  afterwards 
a  firm  elastic  swelling  nearly  filled  up  the  throat.   This  was  punc- 

*  Diseases  of  Children,  by  Lewis  Smith,  M.D.,  1869,  p.  319. 
11 


162  DISEASES   OF   CHILDREN. 

tured  with  a  bistoury,  aud  a  large  quantity  of  pus  evacuated.   The 
child  recovered.* 

The  abscess  can  generally  be  detected  on  obtaining  a  view  of  the 
pharynx  and  fauces,  wdien  it  is  seen  to  push  forward  the  posterior 
wall  of  the  pharynx  against  the  velum  palati,  or,  if  lower  down, 
obstructing  the  larynx  and  involving  the  respiration.  The  pus  may 
even  extend  downwards  into  the  pleural  cavity,  and  excite  danger- 
ous mischief  within  the  w^alls  of  the  thorax. 

When  dyspnoea  threatens  there  is  danger  of  suffocation,  and 
coughing  or  swallowing  increases  the  paroxysms;  the  head  is 
thrown  back  and  the  patient  sits  upright,  with  the  tongue  pro- 
truding from  the  mouth;  the  pulse  is  frequent  and  small,  the 
aspect  is  livid,  and  death  occurs  from  apncea.  In  some  rare  in- 
stances the  abscess  has  burst  and  deluged  the  trachea  and  bron- 
chi, causing  death  by  suffocation. 

In  the  case  of  a  child  three  years  of  age,  recorded  by  Dr.  C. 
Elliot,  of  the  Bristol  Children's  Hospital,  slowly  increasing  dys- 
phagia was  the  leading  feature,  followed  by  convulsions  and  death. 
ISTothino-  could  be  detected  on  examination  but  some  redness  of 
the  fauces  and  slio;ht  enlarajement  of  the  tonsils.  There  was  no 
dyspnoea.  Beef  tea  and  brandy  w^ere  introduced  into  the  stomach 
through  a  gum  elastic  catheter.  After  death  "  an  abscess  contain- 
ing about  two  ounces  of  pus  was  found  situated  in  the  upper  and . 
posterior  wall  of  the  pharynx."  There  was  no  disease  of  the  bone, 
and  the  larynx,  and  tonsils  were  healthy. f 

Diagnosis. — The  disease  may  be  mistaken  for  croup,  but  the 
peculiar  cough  of  the  latter  should  distinguish  it,  and  the  insidi- 
ous manner  in  which  retropharyngeal  abscess  creeps  on ;  it  is 
much  slower  in  its  development,  and  the  respiration  is  not  in- 
volved till  a  late  period.  The  complaint  is  quicker  in  its  progress 
when  it  follows  the  exanthemata  than  when  it  arises  from  disease 
of  the  spine. 

Treatment. — When  the  abscess  is  detected  it  should  be  opened 
with  a  bistoury,  in  the  median  line,  without  delay,  and  the  finger 
will  sometimes  detect  fluctuation  when  an  inspection  of  the  fauces 
fails  to  discover  anything  wrong.  For  a  day  or  two  after  the 
puncture  the  tumor  should  be  occasionally  pressed  with  the  finger 
to  squeeze  out  any  accumulation  of  matter,  and  if  the  case  goes 

*  Brit.  Med.  Journal,  1874,  vol.  ii,  p.  371. 
t  II).,  1879,  veil,  i,  p.  663. 


DISEASES   OF   THE    MOUTH   AND    FAUCES.  163 

on  well  recovery  will  take  place  in  two  or  three  weeks.  If  the 
abscess  is  detected  early  and  opened  the  majority  of  the  cases  will 
recover,  but  if  due  to  disease  of  the  spinal  column  they  are  gener- 
ally^ fatal.  After  puncture,  cod-liver  oil,  the  sj^rup  of  iodide  of 
iron,  quinine,  nourishing  diet,  and  pure  air  wnll  complete  the  cure. 

Cynanche  parotidea — parotitis  or  mumps — is  a  contagious  and 
common  disease  in  children,  often  occurring  as  an  epidemic  in 
schools,  or  other  places  where  a  large  number  of  young  persons 
are  living  under  the  same  roof.  Sporadic  cases  are  occasionally 
met  with,  and  boys  are  far  more  frequently  attacked  than  girls. 
The  disease  consists  in  inflammation  of  one  or  both  parotid  glands, 
sometimes,  however,  attacking  one  side  of  the  face  only,  and  ter- 
minating in  resolution ;  the  testicles  of  boys,  and  the  breasts  and 
ovaries  of  girls,  occasionally  sympathize  in  the  swelling,  especially 
when  the  afi'ection  begins  to  decline.  Ordinary  mumps  is  usually 
excited  by  exposure  to  cold,  and  runs  its  course  in  four  or  five 
days.  When  one  member  of  a  family  suffers  the  others  also  be- 
come affected,  though  some  authorities  (with  whom  I  cannot  agree) 
assert  that  the  complaint  is  not  infectious.  When  the  blood  is 
contaminated  by  typhus,  and  some  other  fevers,  inflammation  of 
the  parotid  may  terminate  in  suppuration. 

According  to  Virchow  the  disease  commences  in  the  gland  ducts 
rather  than  in  the  interstitial  tissue  of  the  parotid.  W^hen  it  arises 
from  simple  catarrh,  the  tendency  to  suppuration  is  much  less  than 
when  it  originates  in  catarrhal  inflammation  of  the  gland  ducts. 

The  symptoms  are  febrile  disturbance  and  headache ;  there  is 
stiffness  and  pain  in  opening  the  jaws,  and  swelling  takes  place 
between  the  cheek  and  the  ear,  extending  down  the  neck  along 
the  ramus  of  the  jaw  to  the  submaxillary  gland.  The  face  is 
sometimes  flushed  and  the  child  is  very  restless,  and  even  wanders 
at  night. 

Treatraent. — If  there  is  much  swelling  two  or  three  leeches  may 
be  necessary,  and  a  poultice  applied  afterwards,  but  warm  fomen- 
tations and  a  piece  of  flannel  carried  under  the  chin  usually  suflice 
to  bring  about  a  cure.  A  saline  and  cooling  aperient  is  desirable 
to  relieve  the  feverish  symptoms  and  open  the  bowels.  The  diet 
should  be  exclusively  fluid,  consisting  of  milk,  thin  arrowroot,  tea, 
etc.  If  the  gland  remains  enlarged  after  the  acute  symptoms  have 
subsided  it  leads  to  no  bad  consequences,  and  disappears  in  the 
course  of  time. 


164  DISEASES   OF   CHILDREN. 

CHAPTER  XIY. 

INDIGESTION. 

State  of  the  digestive  orgaxs  in  infancy  and  childhood  :  Influence  of  den- 
tition on  the  digestive  process — Chymification — Chylification — Absorption — Defecation 
— Sympathetic  disturbance  in  other  organs — Digestion  of  different  principles  of  food, 
starch,  sugar,  and  fat — Sugar  ivHl  not  replace  fat — Nitrogenous  elements  of  food — 
Influence  of  weaning  on  digestion — Emotioned  indigestion — Solid  meat  not  required  till 
molar  teeth  appear.  Symptoms  :  Symptoms  of  the  different  varieties  of  indigestion — 
Yomiting — Pain — Intestinal  irritation  —Eczematous  eruptions  — Anorexia —  Vitiated 
appetite — Bulimia — Pyrosis.  Causes:  Atrophy — General  debility  or  inherited  weak- 
ness— Improper  or  deficient  feeding — Excess  of  animal  food-.  Treatment  :  Alkalies 
— Calumba — Bark — Mineral  acids — Nux  vomica — Citrate  of  iron  and  quinine. 

The  functions  of  the  digestive  system  in  infancy  differ  in  a 
remarkable  desfree  from  those  of  adult  life  when  the  orsrans  con- 
cerued  have  reached  a  higher  state  of  development.  The  calls  for 
nourishment  to  meet  the  changes  that  are  perpetually  going  on  in 
the  child  are  frequent,  and  too  much  care  and  importance  cannot 
be  devoted  to  this  early  period,  when  the  stomach  is  so  constantly 
occupied  in  preparing  the  food  that  is  introduced  into  it  for  ab- 
sorption and  nutrition. 

Children  may  be  compared  to  small  birds  whose  circulation  and 
respiration  are  very  rapid,  while  the  machinery  of  life  is  in  active 
motion  ;  in  fact  they  live  fast.  These  tiny  creatures  are  contin- 
ually pecking  up  food  to  compensate  for  the  incessant  waste  in 
their  physical  economy.  But  the  balance  between  waste  and 
repair  is  soon  overcome  in  favor  of  the  former,  and  small  birds 
are  short  lived.  In  children,  owing  to  the  further  development  of 
the  organs,  the  process  of  repair  is  in  excess  of  waste  and  leads  to 
growth. 

Indigestion  is  most  common  in  infaucv,  and  decreases  with 
growth  and  the  completion  of  the  first  dentition,  when  the 
stomach  in  health}^  children  becomes  capable  of  bearing  a  mixed 
diet.  The  digestive  organs  in  early  life  will  only  assimilate  the 
simplest  diet,  and  any  deviation  from  it  will  be  followed  by  dis- 
comfort, and  symptoms  which  make  up  the  sum  total  of  indiges- 
tion. 

In  the  predental  period  of  infancy  the  food  reaches  the  stomach 
almost  as  soon  as  it  is  introduced  in  the  mouth  without  mastica- 
tion.    When  once  it  is  in  contact  with  the  gastric  mucous  mem- 


INDIGESTION.  165 

brane,  a  secretion  is  poured  out ;  and  the  two  combining  form  a 
substance  called  chyme,  and  the  process  is  termed  chymijieaiion. 
The  next  step  consists  in  the  action  of  the  muscular  coat  of  the 
stomach  walls,  forcing  the  fluid  mass  through  the  pyloric  orifice 
into  the  duodenum,  where  mixing  and  becoming  incorporated 
with  the  biliary  and  pancreatic  secretions  it  is  transformed  into  a 
creamlike  substance  termed  chyle^  and  this  process  is  called  chyli- 
jicaiion.  The  villi  which  are  scattered  over  the  surface  of  the 
small  intestine  absorb  the  nutritive  elements,  and  convey  them 
into  the  lacteals,  and  so  into  the  circulation  through  the  recep- 
taculum  chyli.  Those  portions  of  the  food  which  are  useless,  or 
resist  absorption,  are  conveyed  along  the  remaining  tract  of  intes- 
tine and  finally  thrown  out  of  the  body  as  excrementitious  matter, 
and  this  process  is  termed  defeoation.  In  a  state  of  health  these 
processes  are  carried  on  without  our  consciousness,  and  a  sense  of 
comfort  and  satisfaction  only  is  felt.  Where  digestion  is  imper- 
fectly performed*,  either  from  defective  health,  or  from  the  quality 
of  the  food  that  has  been  taken,  then  indigestion  results,  and  the 
symptoms  that  ensue  are  oppression,  pain,  weight,  and  distension. 
The  food  is  either  rejected  by  vomiting,  delayed  in  the  stomach, 
or  passed  on  into  the  bowels,  causing  diarrhoea,  or  some  other 
form  of  irritation  in  these  viscera. 

"We  have  here  to  consider  what  happens  in  infants  and  very 
young  children  in  these  cases.  There  is  deranged  action  in  the 
stomach  itself,  an  alteration  in  the  character  of  the  secretion,  and 
irregular  or  unhealthy  muscular  action.  But  indigestion  once 
established  does  not  limit  the  resulting  disturbance  to  the  stomach 
itself;  it  involves  by  sympathy  other  and  distant  organs,  and 
there  is  not  an  important  viscus  in  the  w'hole  body  that  does  not 
share  in  the  general  derangement,  so  much  so,  that  it  frequently 
distracts  our  attention  from  the  stomach,  and  deludes  us  into 
looking  at  the  sympathetic  disturbance  as  the  primary  evil. 

In  children,  as  in  adults,  the  stomach  may  have  lost  its  vigor 
and  tone,  and  therefore  be  incompetent  to  fulfil  its  functions  ;  but 
in  the  vast  number  of  instances  indigestion  originates  from  the 
quality  and  quantity  of  food  that  is  introduced  into  it.  The 
mucous  membrane  is  readily  irritated,  and  resists  the  oflfence,  just 
as  any  other  organ  of  the  body  becomes  irritated  by  some  abnor- 
mal  stimulation,    and   finally   fails  under   the   excitement,  even 


166  DISEASES    OF    CHILDREN. 

though  there  may  he  no  discoverahle  alteration  or  gross  structural 
change. 

Hence,  then,  it  is  proverbial  in  early  life  that  the  stomach  being 
delicate  and  susceptible  to  any  disturbance,  we  should  be  most 
careful  to  select  a  proper  diet,  to  consider  the  quality  of  food  that 
is  supplied,  to  measure  the  capabilities  of  the  digestive  system,  and 
to  deal  with  theni  accordingly. 

We  have  no  need  to  pursue  more  than  cursorily  the  question  of 
mastication,  because  it  is  the  digestion  of  infancy  we  are  now 
mainly  concerned  with,  and  yet  it  is  necessary  to  allude  to  tbe 
development  of  the  teeth.  There  are  two  sets  of  teeth,  the  deciduous 
and  the  permanent.  In  infancy  there  is  a  period  of  several  months 
before  any  teeth  are  developed,  and  when  therefore  the  function 
of  mastication  is  not  required.  In  the  early  months  of  life  there  is 
no  secretion  of  saliva.  (Pavy).  The  mother  provides  the  necessi- 
ties of  living  in  the  form  of  milk,  which  her  child  consumes  till 
growth  and  development  fit  it  for  an  independent  existence.  Ey 
the  time  when  the  mother  should  wean  her  child  at  seven  or  eight 
months,  the  teeth  begin  to  appear,  and  by  the  end  of  the  first  year 
in  healthy  children  there  are  usually  as  many  as  twelve.  There  is 
no  longer  need  for  a  fluid  diet  exclusively,  but  among  the  lower 
classes,  prolonged  lactation  to  diminish  the  risk  of  repeated  preg- 
nancies, is  carried  far  beyond  the  limits  of  health  in  the  mother  or 
her  offspring.  Chiklren  of  fifteen  or  sixteen  months  old  may  often 
be  seen  clinging  to  the  breast  for  their  only  sustenance  in  the 
out-patient  department  of  our  hospitals. 

When  the  child  is  once  permitted  to  sustain  itself  another  diffi- 
culty is  presented.  In  many  instances  it  is  either  provided  with 
food  which  is  improper,  or  it  devours  it  too  hastily,  and  so  the 
troubles  of  indigestion  are  established.  Food  imperfectly  masti- 
cated resists  the  solvent  action  of  the  gastric  juice,  and  irritation 
of  the  digestive  organs  arises. 

Regarding  the  process  of  insalivation,  the  secretions  of  the 
parotid  and  submaxillary  glands  are  poured  into  the  mouth,  as  well 
as  that  of  the  lingual  and  other  smaller  glands.  Parotid  saliva,  in 
man  at  least,  is  water}',  and  acts  as  a  solvent;  submaxillary  saliva 
is  more  viscid,  and  contains  more  of  the  active  principle,  ptyalin, 
w^hich  converts  starch  into  glucose  or  grape-sugar. 

Digestion  of  Starch. — Starch  is  a  non-nitrogenous  principle, 
entering  largely  into  the  composition  of  some  foods.     Whilst  it 


INDIGESTION.  167 

remains  in  this  condition  it  resists  absorption  till  tlie  digestive 
system  exerts  its  influence  upon  it.  The  first  conversion  is  into 
dextrin,  which  mnch  resembles  starch,  and  then  into  sugar,  Avhich 
is  easily  absorbed.  The  action  of  the  saliva  converts  starch  into 
sugar  when  the  process  of  mastication  is  properly  carried  on.  As 
the  food  passes  out  of  the  stomach,  the  secretion  of  the  pancreas 
and  the  fflands  linino;  the  mucous  membrane  of  the  intestines 
exert  their  action  upon  the  remaining  starch,  and  further  trans- 
formation into  sugar  takes  place,  and  the  bloodvessels  convey 
the  latter  into  the  circulation,  whilst  the  unchanged  starch- 
granules  mix  with  the  evacuations  and  are  carried  out  of  the 
system.  Starch  is  not  naturally  a  part  of  the  food  of  very  young 
infants  when  the  digestive  functions  are  imperfectly  developed. 
Sugar  is  the  form  that  suits  them.* 

Digestion  of  Sugar. — This  is  principallj^  the  cane  sugar  which 
exists  as  a  juice  in  many  plants.  It  is  so  readily  soluble  that  the 
digestive  functions  are  in  no  degree  taxed  when  it  enters  the 
stomach,  by  which  it  is  readily  absorbed  into  the  circulation, 
undergoing  a  change  into  grape-sugar. 

In  some  forms  of  dyspepsia,  and  especially  in  that  of  children, 
lactic,  butyric,  and  other  acids  may  be  present  as  secondary 
products,  arising  either  by  their  respective  fermentations  from 
articles  of  food,  or  from  decomposition  of  their  alkaline  or  other 
salts;  and  the  tendency  is  immensely  increased  by  saccharine 
articles  of  diet. 

The  envelopes  of  the  fat-cells  are  dissolved  by  the  gastric  juice, 
and  their  contents  set  free  These  run  into  droplets,  and  are  passed 
on  into  the  small  intestines,  where  they  are  acted  upon  by  the  bile, 
and  the  pancreatic  secretion.  By  the  agency  of  these  the  greater 
part  of  the  fat  is  emulsified,  and  therefore  rendered  capable  of 
absorption ;  partly  split  up  into  fatty  acids  and  glycerin,  and  partly 
saponified.  The  absorption  of  fat  appears  to  be  of  a  physical  rather 
than  of  a  chemical  nature. 

State  of  Digestion  at  the  Time  of  Weaning. — In  even  healthy  children 
this  seldom  takes  place  without  causing  some  disturbance  in  the 
constitution,  and  the  symptoms  that  arise  are  generally  those  that 
indicate  disorder  in  the  functions  of  digestion.  The  change  of 
food  when  the  mother  ceases  to  suckle  her  child  is  fraught  with 
risk  for  some  time,  the  child  is  fretful  and  sleepless,  has  flatulence, 

*  See  Chap.  II,  p.  36,  where  this  subject  is  more  fully  considered. 


168  DISEASES    OF   CHILDREN. 

diarrlioea,  or  vomiting,  and  forthwith  it  declines,  looks  pinched  and 
careworn, has  a  weak  cry,  and  the  skin  shrivels  from  the  absorption 
of  the  subcataneons  fat,  redness  about  the  arras  and  thighs  is 
observed,  and  the  changed  aspect  is  remarkable.  JSTot  that  this 
abnormal  condition  ensues  in  all  cases,  for  many  healthy  infants 
bear  the  change  without  manifesting  either  local  or  constitutional 
disturbance. 

Indigestion  is  constantly  associated  with  wasting  in  children  ; 
when  they  are  so  suffering,  the  food  that  is  swallowed  is  at  once 
rejected  ;  they  lose  color  and'streugth,  the  muscles  waste,  and  the 
limbs  become  attenuated.  The  child  refuses  the  breast  or  takes 
it  greedily ;  then  begins  to  whine  and  cry,  and  can  obtain  no  ease 
till  the  milk  is  rejected,  because  the  digestive  powers  are  unable 
to  assimilate  it.  In  addition  to  these  sj-mptoms  others  arise,  as 
heat  about  the  mouth,  with  pain  and  acid  eructations  ;  the  motions 
are  often  slimy,  offensive,  and  of  a  dark-greenish  hue,  or  they  are 
pebbly,  and  there  is  constipation.  When  the  child  is  fed  on  milk 
or  has  a  wet-nurse  the  motions  may  be  pale  and  almost  like  the 
milk  that  is  swallowed,  which  passes  through  the  bowels  un- 
changed ;  or  the  motions  are  variable  in  character  (diarrhoea  alter- 
nating with  constipation),  being  loose  and  thin  at  one  time,  and 
sticky  and  clay-colored  at  another,  with  green  spots  like  bits  of 
spinach  among  them. 

Vomiting^  so  frequently  present  in  these  cases,  is  a  reflex  action 
of  the  nervous  system,  and  is  a  common  symptom  of  indigestion, 
or  irritability  of  the  stomach  in  infancy  and  childhood.  It  is  also 
symptomatic  of  disease  of  the  brain,  of  the  lungs,  of  the  various 
exanthemata,  and  diarrhoea  depending  on  poisoned  blood.  It  is  a 
symptom  that  invariably  excites  alarm  when  it  arises  without  any 
discoverable  cause,  and  cannot  be  attributed  to  overfeeding  or 
mechanical  irritation.  It  usually  happens  that  the  milk  does  not 
agree,  either  from  fatigue,  indiscretion  in  diet,  or  bad  health  in  the 
nurse  ;  what  is  swallowed  soon  causes  flatulence  and  pain  till  it  is 
finally  rejected  as  a  curd  from  the  stomach,  and  the  child  at  once 
seizes  the  breast  again  till  the  same  symptoms  recur,  or  after 
some  discomfort  it  passes  through  the  stomach  and  creates  intes- 
tinal irritation  and  diarrhoea.  The  same  is  likely  to  ensue  when 
the  milk  is  healthy,  but  the  child  has  been  allowed  to  go  too  long 
without  food,  or  is  fiitigued  from  heat  or  overexcitement.  If, 
from  any  of  these  circumstances,  vomiting  ensues,  it  is  important 


INDIGESTION.  169 

to  allow  the  stomach  rest,  and  whilst  its  tone  is  lost,  to  give  a  tea- 
spoonful  of  cold  water  or  barley-water,  till  the  sickness  has  passed 
off.  When  the  symptoms  do  not  yield  to  these  measures,  and  the 
child  is  otherwise  in  good  health,  a  mild  mercurial  and  milk  and 
lime-water  given  by  a  teaspoon  will  generally  aftbrd  relief.  It  may 
at  the  same  time  be  advisable  to  prescribe  small  doses  of  hydro- 
cyanic acid  in  a  solution  of  magnesia,  and  to  apply  a  mustard 
poultice  to  the  epigastrium, 

Durino;  the  continuance  of  this  state  of  thino-s  the  child  is 
weakly,  and  an  erythematous  rash  may  appear  on  the  buttocks, 
or  eczema  on  the  face  and  scalp.  I  have  seen  this  appear  and  dis- 
appear according  to  the  severity  of  the  indigestion,  and  in  one  case 
it  was  so  bad  that  the  ej-elids  became  oedematous  from  the  swell- 
ing and  the  features  distorted. 

Anorexia  is  a  common  symptom  in  dyspepsia,  and  when  it  is 
present  children  will  struggle  to  the  utmost  rather  than  swallow 
one  particle  of  food.  Vitiated  appetite  is  sometimes  seen  in  chil- 
dren. In  one  case  under  my  care,  a  girl  suflfering  from  anasarca 
and  albuminuria,  devoured  the  most  loathsome  things  possible, 
and  required  careful  watcliing  to  prevent  her  from  so  doing. 

JBulimia  is  seen  amono;  children  sufferino;  from  worms  in  the  in- 
testinal  canal  or  mesenteric  disease.  It  is  also  very  common  in 
cases  of  chronic  hydrocephalus,  and  is  by  no  means  rare  during 
convalescence  from  measles  and  some  otlier  acute  diseases.* 

Then  there  is  a  form  of  dyspepsia  not  uncommon,  especially  in 
boys.f  The  tongue  loses  its  epithelium  and  is  superficial!}'  ulcer- 
ated. Children  thus  affected  bolt  their  food  and  have  ravenous 
aj^petites.  They  lose  flesh  and  do  not  thrive ;  they  are  pallid  and 
delicate-looking,  and  if  the  condition  is  allowed  to  go  on  it  may 
pass  into  mesenteric  disease. 

In  some  cases  dj-spepsia  and  intestinal  irritation  are  brought  on 
by  giving  young  children  too  much  animal  food,  which  they  swal- 
low without  suflficientlj'  masticating  it.  After  a  time,  in  addition 
to  epigastric  pain,  tenesmus  and  bearing  down  ensue,  the  child 
wishing  to  go  to  the  closet  every  minute  ;  the  motions  are  lump}", 
thick,  and  brown,  with  jellylike  clots  of  blood  on  them,  and  there 
are  faintness  and  nausea  before  the  bowels  act.  This  form  of  in- 
digestion may,  if  the  symptoms  are  not  attended  to,  pass,  into  dys- 

*  See  Chapter  X.  f  See  Chapter  II. 


170  DISEASES    OF    CHILDREN. 

enteric  diarrhoea,  and  the  child  may  die  of  mesenteric  disease  and 
phthisis. 

Pyrosis  is  sometimes  seen  in  children  of  eiglit  or  nine  years  of 
age,  demanding  the  same  line  of  treatment  as  in  the  adult. 

The  causes  of  indigestion  in  infants  arise  in  nineteen  cases  out  of 
twenty  from  defective  power  on  the  part  of  the  stomach  to  assimi- 
late and  digest  the  food  that  is  supplied,  or  to  the  food  not  being 
always  of  the  most  digestible  quality,  I  remember  a  lady  who 
had  live  children,  and  all  of  them  reached  the  age  of  one  year 
without  any  illness  or  drawback.  All  the  five  children  were  wet- 
nursed.  The  sixth  child  was  born  at  the  full  term,  and  in  every 
respect  was  strong  and  vigorous.  A  healthy  wet-nurse  was  pro- 
cured whose  milk  presented  microscopically^  no  deviation  from  the 
healthy  standard,  she  w'as  twenty-five  years  old,  and  all  her  func- 
tions were  regular.  The  child  at  the  ao;e  of  two  months  had  an 
erythematous  eruption  of  the  face  and  scalp,  attended  with  great 
itching  and  much  redness.  Small  vesicles  and  prominent  elevated 
points  soon  appeared  over  the  inflamed  parts,  and  finally  ran  into 
one  another,  causing  excoriation  and  superficial  ulceration  of  the 
surface.  The  tongue  was  clean  and  without  aphthae,  the  surface  of 
the  body  healthy,  and  there  were  seldom  less  than  three  or  four 
motions  in  the  twenty-four  hours,  of  a  bright-3'ellow  color.  The 
child  occasionally  brought  up  a  curdlike  mass  of  milk,  almost  as 
soon  as  swallowed,  and  the  uneasiness  evinced  by  a  whining  cry, 
and  the  incessant  drawing  up  of  the  extremities,  would  often  mo- 
mentarily cease,  after  lasting  many  hours,  by  the  expulsion  of  wind 
from  the  stomach,  or  by  the  action  of  the  bowels.  This  was  clearly 
owing  to  indigestion,  and  imperfect  assimilation  of  the  milk  taken  ; 
either  it  w^as  too  rich,  or  the  stomach  too  feeble  to  exert  the  neces- 
sary changes,  or  the  mucous  membrane  secreted  an  undue  amount 
of  acid,  and  caused  fermentation  in  the  food  products.  Barley- 
water,  substituted  for  a  time,  would  arrest  sickness  and  spasms, 
and  so  would  isinglass  and  water,  and  then  the  child  would  return 
again  to  the  nurse's  milk  for  a  few  days  without  any  inconvenience. 
Jjut  after  a  time  the  same  inconvenience  would  return,  and  then  it 
was  finally  determined  to  discard  tlie  nurse,  and  try  the  eft'ect  of 
cows'  milk  with  an  equal  quantity  of  water,  and  one  tablespoonful 
of  lime-water  to  the  bottle.  A  third  of  a  bottleful  was  allowed  at 
each  feeding  at  intervals  of  two  hours.  Immediately  the  change 
of  diet  was  instituted,  a  remarkable  improvement  set  in,  the  erup- 


INDIGESTION.  171 

tion  began  to  fade,  and  the  child  was  brisk  and  lively.  But  after 
a  few  more  days  had  elapsed  the  same  colicicy  pains  and  flatulence 
returned,  the  child  was  pale  and  pinched,  and  the  motions  became 
acrid,  offensive,  white,  and  sticky.*  It  was  obvious  that  the  liver 
was  not  pouring  out  its  proper  biliary  secretion,  and  to  meet  this, 
a  powder  containing  a  grain  of  gray  jDOwder,  two  grains  of  rhu- 
barb, and  half  a  grain  of  cinnamon  powder,  was  given  every  night, 
whilst  a  carminative  mixture  of  bicarbonate  of  potash,  sal  vola- 
tile, and  dill-water  was  given  at  intervals  during  the  day.  About 
twenty  drops  of  brandy  were  added  to  each  bottle  of  milk.  An 
improvement  soon  set  in,  the  motions  assumed  a  more  healthy 
character,  and  the  child  became  bright,  the  features  filled  out,  it 
slept,  and  enjoyed  the  food,  which  now  caused  scarcely  any  flatu- 
lence or  discomfort.  A  still  further  manifestation  of  improvement 
w^as  shown  in  the  decline  of  the  eczematous  eruption,  once  so  per- 
sistent and  troublesome,  but  now  fading  with  the  child's  better 
nutrition,  and  only  giving  evidence  of  its  latency  by  occasionally 
showing  itself  when  the  digestive  functions  were  temporarily  dis- 
turbed. 

The  alimentary  canal  is  extremely  sensitive  in  early  life,  and  a 
mother  learns  from  experience  that  if  she  is  careless  in  keeping  her 
own  digestion  in  proper  order  she  is  sure  to  derange  that  of  her 
oflTspring.  After  the  seventh  or  eighth  month,  when  the  teeth 
begin  to  appear,  the  child  wall  need  some  solid  article  of  food,  and 
it  fs  then  that  biscuits  and  some  farinaceous  articles  of  diet  may 
be  given  with  the  milk,  later  on  a  little  beef  tea  or  gravy,  but  not 
meat,  till  the  second  year.  The  irritation  caused  by  the  coming 
molar  teeth  induces  the  child  to  make  masticatory  efibrts,  and  this 
excites  the  action  of  the  salivary  glands. 

The  other  causes  of  indigestion  are  an  impure  atmosphere  and 
confined  rooms,  especially  if  several  children  occupy  the  same 
apartment.  Hot  sultry  weather  will  frequently  induce  the  com- 
plaint, and  children  reared  in  towns  and  cities  are  more  frequent 
sufi:erers  than  those  brought  up  in  the  country.  Artificial  feeding 
is  probably  the  most  frequent  cause,  especially  that  by  the  bottle, 
from  the  liability  of  the  contents  to  turn  sour  and  disorder  the 
digestion.  All  children  so  suflering  should  be  fed  with  a  tea- 
spoon. 

Older  children  experience  indigestion  from  eating  unwholesome 

*  See  Chap.  XV,  On  Diarrhoea. 


172  DISEASES    OF   CHILDREN. 

food,  as  sweets  and  raisins,  cherries,  etc,  wliicli,  undergoing  only 
partial  change,  cause  pain  and  intestinal  irritation.  They  are 
often  feverish  and  drowsy,  have  headache,  and  are  disinclined  to 
move;  they  hring  up  what  is  swallowed,  and  complain  of  pain 
over  the  epigastrium.  Their  nights  are  restless,  and  the  nervous 
system  is  so  upset  that  a  convulsion  may  follow.  The  neglect  or 
continuance  of  the  disease  may  lead  to  aphthous  ulceration  of  the 
mouth,  diarrhcea,  or  eclampsia. 

Treatment. — In  addition  to  the  hints  and  suggestions  already 
thrown  out  in  this  chapter,  concerning  food  and  judicious  feeding, 
there  are  other  matters  to  be  recollected.  Three  conditions  appear 
to  be  necessary  to  ward  off  indigestion  in  an  infant,  and  when 
they  exist,  it  is  remarkable  how  slight  is  the  stomach  derange- 
ment. These  conditions  are:  1.  The  child  to  be  healthy  born  ; 
2.  The  mother  to  be  healthy,  if  she  supports  her  own  child;  3. 
The  cow's  milk  used  to  be  pure,  from  the  same  cow,  and  to  be 
properly  diluted. 

The  cause  in  operation  requires  to  be  diligently  sought  for,  and 
a  careful  inquiry  should  be  made  into  the  circumstances  of  each 
individual  case  in  order  to  remove  it.  It  sometimes  happens  that 
an  emetic  will  get  rid  of  the  offending  material  at  once. 

Care  in  nursing  and  proper  feeding  will  often  cure  the  disorder. 
The  fixed  alkalies  of  lirae  and  magnesia  may  be  added  to  the  milk. 
If  there  is  acidity,  an  occasional  powder  of  soda  and  rhubarb  is  of 
service,  and  a  grain  or  two  of  mercury  and  chalk  may  be  added 
when  the  biliary  secretion  is  deficient.  It  is  a  good  plan  to  give 
alkalies  when  there  are  free  acids  generated  in  the  stomach;  a 
grain  or  two  of  bicarbotiate  of  potash  with  sal  volatile  will  pre- 
vent the  coagulation  of  the  milk  and  the  formation  of  a  curd. 
Dandelion  and  calumba  may  be  added  if  the  stomach  has  lost  its 
tone  and  the  liver  is  inactive.* 

Alkalies  ought  not  to  be  continued  for  too  long  a  period,  and  the 
circumstance  that  curd  is  vomited  by  no  means  implies  that  there 

*  Formula  19: 

R.  Sodffi  bicarb., gr.  xij 

Spt.  amra.  arom. "^.tij 

Syr.  rhei,  ve]  sncci  taraxaci, giij 

Tinct.  cahinilia;,  .         .         .         .         .         .        .         •  5J 

Aqiiam  anetlii  ad       . siss. — M. 

3ij  ter  die.     For  children  a  year  old. 


INDIGESTION.  173 

is  acid  in  the  stomach,  hecanse  the  gastric  juice  may  be  insufficient 
and  the  stomach  weak.  In  that  case  the  mineral  acids  are  suit- 
able to  the  youngest  child,  the  hydrochloric  or  nitric  acid,  or  both 
combined.*  If  there  is  sickness  and  debility,  with  scanty  secretion 
from  the  liver,  hydrocyanic  acid  in  combination  with  nitric  acid 
may  be  given. f  Bark  and  nux  vomica  are  also  useful  in  some 
cases. t 

Indigestion  in  children  sometimes  assumes  an  exceedingly  acute 
form.  From  being  comparatively  well,  a  child  becomes  suddenly 
ill,  restless,  and  feverish ;  its  circulation  and  respiration  are 
excited,  and  its  temperature  runs  up  to  103°,  or  even  higher ;  the 
mother  thinks  the  child  has  caught  cold,  or  is  commencing  some 
feverish  attack,  but  the  suddenness  and  character  of  the  seizure 
render  this  view  unlikely.  This  suddenness  is  the  great  charac- 
teristic of  acute  indigestion,  and  at  once  points  to  the  real  cause, 
and  relieves  the  anxiety.  In  such  cases  it  is  well  to  give  an  emetic 
of  ipecacuanha,  with  a  little  antimonial  powder  and  calomel.  The 
child  vomits,  is  at  once  somewhat  better,  and  if  its  bowels  are 
opened  subsequentlj^,  in  a  few  hours  the  alarming  symptoms  dis- 
appear. The  quickness  of  the  decline  corresponds  to  the  acute- 
ness  of  the  attack. 

In  chronic  indigestion  change  of  air  is  very  serviceable,  and 
one  wet-nurse  may  have  to  be  changed  after  another ;  calumba, 
bark,  and  nitric  acid  are  useful  in  these  cases.     In  older  children, 

*  Formula  20 : 

R.   Acid.  nit.  dil., nj^xij 

Acid,  hydroch.  dil., .     fijjxxiv 

Tinct.  calumbse,       ........     gj 

Syr.  aurant,     .         .         .         .         .         .         .         .         .     ^ij 

Aquam  ad       ........         .     ^ij. — M. 

5j  ter  die.     For  children  a  year  old. 
t  Formula  21  :      , 

B-    Acid,  hydrocyan.  dil., ^^\) 

Acid,  nitric,  dil., t^xx 

Syrupi, ^ij 

Aquam  ad ^iss. — M. 

3j  ter  die.     For  children  a  year  old. 
t  Formula  22 : 

R.    Tinct.  cinch,  co., 5iss. 

Tinct.  nucis  vom., ^xij 

Syrupi .i^ij 

Aquam  ad giss. — M. 

3j  ter  die.     For  children  a  year  old. 


174  DISEASES   OF  CHILDREIS". 

the  citrate  of  iron  and  quinine  is  a  valuable  remedy  if  there  is 
ansemia. 

Dr.  Lauder  Brunton  advocates  for  children  with  defective 
digestion,  stale  bread  cut  very  thin,  and  the  butter  well  rubbed 
into  it,  in  preference  to  bread  cut  thick,  with  a  thick  layer  of 
butter,  commonly  seen  in  the  nursery.  In  doing-  this  the  fat 
becomes  finely  subdivided,  resembling  the  condition  found  in 
milk. 


CHAPTER    XV. 

DIARRHGEA. 


Varieties — 1.  Simple  diarrhcea  {catarrhal  diarrhcea) — 2.  Bilious  diarrhoea — 3.  Chol- 
eraic diarrhoea  {cholera  infantum) — 4.  Congestive  or  inflammatory  diarrhoia  {chronic 
muco-enteritis,  mucous  diarrhoea,  entero-colitis) — Thermic  diarrhoea — 5.  Lientery 
{lienteric  diarrhosa) — 6.  Dysenteric  diarrhxa — Symptoms  of  the  different  forms — 
Green  stools,  their  causes  and  significance  —  Clay-colored  pasty  stools  —  Chronic 
diarrhea — The  result  of  persistent  simple  diarrhcea,  or  the  other  varieties — Causes 
of  diarrhma — Dentition — Oversuckling  —  Impure  air  and  water — Filth  and  orer- 
crowding — Irritating  food — Sour  milk — Cold — Diispepsia — Congestion  of  the  liver — 
Artificial  feeding — Sometimes  a  complication  of  rickets,  whooping-cough,  and  measles — 
Treatment  of  simple  diarrhoea— Castor  oil — Dover'' s  powder — Bismuth — Ipecacuanha — 
Astringents— Warmth — Rest — Stimulants  in  cases  of  exhaustion — Rhubarb — Treat- 
ment of  the  choleraic,  and^  remaining  acute  forms  of  diarrhoia — Treatment  of  chronic 
diarrhoea — Raw  meat  juice — Extract  of  malt — Acetate  of  lead — Gallic  acid — Logwood 
—  Catechu — Kramer ia — Sulphuric  acid — Syrup  of  red  gum — Extract  of  Bael — Sul- 
phate of  copper  and  opium — Astringent  enemata — Change  of  air — Prolajjsus  ani — Its 
causes  and  treatment. 

Diarrhcea  is  produced  by  many  conditions,  and  among  children 
is  more  often  a  salutary  than  a  diseased  process.  It  is  of  common 
occurrence  when  a  septic  poison  is  generated  from  the  decomposi- 
tion of  vegetable  matter,  or  the  atmosphere  is  charged  with 
miasmatic  effluvia.  After  absor^^tion  through  the  lungs  into  the 
blood,  the  intestinal  raucous  membrane  becomes  irritated  and 
excited,  in  virtue  of  an  inherent  disposition  on  the  part  of  the 
economy  to  eliminate  these  noxious  agents.* 

We  meet  with  it  again,  when  water  containing  organic  impuri- 
ties, obtained  from  the  vicinity  of  graveyards  and  stagnant  pools, 
is  used  for  drinking  purposes.     When  contaminated  with  fetid 

*  See  Lectures  on  the  Infective  Processes  of  Disease,  by  J.  Burdon  Sanderson,  M.D., 
LL.D.,  F.R.S.,  December,  1877. 


DIARRHCEA.  175 

gases,  fermentative  dyspepsia  arises,  and  the  bowels  show  signs  of 
a  disorder,  varying  from  simple  irritation  to  choleraic  purging, 
cramps,  and  loss  of  body  heat.* 

As  a  healthy  process,  a  sharp  attack  of  diarrhoea  proves  its  own 
cure,  irritant  and  offensive  matter  being  thus  got  rid  of  by  the 
bowels,  when  the  stomach  cannot  assimilate  the  food  that  is 
taken.  We  aid  these  efforts  when  nature  fails  to  complete  the 
cure  hj  administering  such  remedies  as  remove  any  morbid  mate- 
rials from  the  system. 

Diarrhoea  is  common  enough  in  infants  when  too  much  milk  is 
swallowed,  or  when  rich  or  sour  milk,  instead  of  being  thrown  up 
by  vomiting,  passes  on  into  the  intestines,  and  creates  irritation 
there.  Exposure  while  dressing,  insufficient  clothing,  the  use  of 
too  cold  water  in  washing,  and  the  neglect  of  cleanliness,  will  all 
induce  excessive  peristaltic  action  of  the  bowels. 

Statistics  clearly  prove  that  there  arc  few  diseases  in  infancy 
and  early  life  of  greater  frequenc}^  or  danger  than  diarrhoea ;  it 
will  often  set  in  from  slight  or  unascertainable  causes,  and  decide 
the  fate  of  a  young  child  in  a  few  hours.  The  delicacy  of  the 
stomach  and  intestines  in  infancy  renders  this  one  of  the  com- 
monest ailments.  If  the  supply  of  food  is  not  of  the  simplest 
kind,  and  given  in  small  quantities  to  suit  the  tender  age  of  the 
child,  the  process  of  digestion  and  absorption  will  be  deranged, 
and  the  local  disturbance  thus  initiated  will  convey  the  irritation 
to  some  other  organ,  and  expose  the  life  of  the  child  to  consider- 
able peril. 

Diarrhoea  in  children  may  be  conveniently  grouped  into  the 
forms  enumerated  at  the  commencement  of  this  chapter.  This  is, 
however,  at  best,  but  an  arbitrary  division,  for  simple  diarrhoea 
may  pass  into  any  of  the  other  varieties,  if  the  irritation  lasts  long 
enough  to  excite  suthcient  disturbance  in  the  mucous  membrane  ; 
and  it  is  often  impossible  to  separate  them  in  practice. 

*  The  diminution  in  the  minjber  of  deaths  from  infantile  diarrhoja  during  the  last 
seven  years  is  mainly  attributable  to  improved  sanitary  legislation,  and  is  far  less  de- 
pendent on  temperature  and  other  atmospheric  conditions  than  is  generally  supposed. 
Indeed,  the  returns  of  the  Registrar-General  for  1877  show  that  the  mortality  of  infants 
from  this  cause  v?as,  during  the  third  or  Michaelmas  quarter,  not  much  more  than  half 
the  average  of  the  seven  preceding  summer  quarters.  The  poor,  in  receiving  higher 
wages,  are  enabled  to  live  in  better  houses,  and  to  obtain  a  superior  quality  of  food. 
This  change  in  their  social  position  will  most  likely  induce  them  to  exercise  greater 
vigilance  than  formerly,  and  will  awaken  them  to  the  danger  of  any  unliealthy  in- 
fluences that  may  spring  up  around  them. 


176  DISEASES   OF    CHILDREN. 

1.  Simple  Diarrhcea  {Catarrhal  d'mvvhcea,). — In  this  variety  there 
is  an  excess  of  natural  action,  the  evacuations  are  copious,  rehixed 
and  frequent,  and  the  child,  if  an  infant,  is  soon  exhausted  in  con- 
sequence. The  attack  may  at  first  be  painless,  and  as  there  is  a 
loss  of  consistence  in  the  motions  they  are  squirted  out  with  spas- 
modic effort.  The  evacuations  are  fecal,  and  if  at  first  greenish, 
they  become  yellow  as  the  symptoms  subside  and  improvement 
sets  in.*  The  early  symptoms  of  simple  diarrhoea  are  hardly  notice- 
able if  the  discharges  are  moderate,  but  there  soon  follow  genea^al 
discomfort  and  peevishness,  the  child  is  disturbed  in  its  sleep,  and, 
perhaps,  becomes  languid  and  paler  than  usual.  The  tongue  may 
be  slightlj'  coated,  and  there  is  usually  some  thirst  and  diminished 
appetite.  AY  hen  the  attack  is  acute  there  is  sickness,  thirst,  and 
dryness  of  the  mouth  ;  the  strength  is  reduced,  and  in  a  few  hours 
the  child  may  be  much  weakened.  The  little  patient  becomes 
sunken  about  the  eyes,  the  features  are  sharpened  and  even  col- 
lapsed, and  the  fontanelles  are  depressed ;  there  is  sometimes  febrile 
disturbance  with  cough  and  bronchial  irritation ;  the  abdomen 
may  be  swollen  and  tender  from  flatulence,  or  concave  and  empty. 
If  the  diarrhrea  goes  on  actively  for  a  day  or  two,  flesh  and  strength 
are  rapidly  lost,  the  muscles  feel  soft  and  flabby,  the  pulse  becomes 
quick  and  feeble,  and  life  is  placed  in  imminent  danger.  The 
change  in  the  character  of  the  evacuations  consists  in  their  being 
thinner  and  more  copious,  though  they  seldom  lose  their  feculent 
appearance,  except  in  very  severe  cases,  or  where  the  disease  is 
obstinate.  In  these  cases  the  motions  soon  become  offensive  after 
escape  from  the  body,  and  may  be  even  greenish  and  slimy. 

When  the  diarrhoea  is  sharp  and  continuous  it  sometimes  in- 
duces so  much  relaxation  of  the  sphincter  as  to  cause  prolapsus 
ani. 

The  anatomical  changes  in  the  lining  membrane  of  the  intestinal 
tract  consist  in  congestion  of  the  vessels,  which  disappears  after 
death.  There  would  seem  to  be  no  pathological  changes  in  the 
simple  form  of  the  complaint,  even  if  it  proceed  to  a  fatal  termi- 
nation. 


*  "The  normal  form  of  the  infantile  faeces  in  the  first  year  is  pappy;  the  color  is 
yellowish,  like  that  of  the  yolk  of  egg  :  the  smell  is  feebly  acid,  never  putrid,  and  only 
in  children  who  are  fed  upon  a  meat  diet  repulsively  pungent,  as  in  the  adult ;  in  later 
years  they  are  no  longer  to  be  distinguished  fi-om  the  adult." — Vor/el,  Diseases  of  Chil- 
dren, 1874,  p.  135. 


DIAREHOEA.  177 

2.  Bilious  diarrhea  may  be  witnessed  in  some  children  who  eat 
inordinately  of  animal  food,  and  live  too  well  for  the  wants  of  the 
system.  Impure  milk,  like  impure  w^ater,  is  capable  of  giving  rise 
to  this  form  of  diarrhcea,  and  in  severe  cases  the  symptoms  may 
become  dj^senteric*  A  large  quantity  of  bile  is  secreted  by  the 
liver  and  poured  out  into  the  intestines,  which  it  irritates.  The 
disease  is  most  common  in  hot  weather,  and  of  course  far  more 
frequent  in  tropical  climates,  when  the  liver  is  apt  to  be  congested 
from  diminished  respiratory  action.  It  arises  from  an  excessive 
secretion  of  bile,  which  stimulates  the  bowels  to  frequent  action, 
the  motions  being  copious,  loose,  and  of  a  dark-yellow  or  green 
color;  the  urine  is  scanty  and  high-colored,  and  may  contain 
traces  of  bile  also.  The  secretion  of  bile  may  be  enough  to  pro- 
voke fever,  unless  it  finds  its  way  freely  out  of  the  system. 

3.  Choleraic  diarrhcea  (cholera  infantum  —  gastro- intestinal 
catarrh — Rilliet  and  Barthez)  is  most  common  in  infants,  and  in 
those  who  are  early  weaned  or  badly  fed.  The  disease  usually 
follows  a  rapid  and  fatal  course.  Its  frequency  is  much  greater 
in  cities  than  in  country  districts,  and  in  summer  and  autumn, 
than  at  other  seasons  of  the  year.  "  It  is  so  frequent  during  the 
period  of  first  dentition,  that  some  writers  consider  dentition  a 
cause."  (Lewis  Smith.)  It  is  in  my  experience  far  more  fre- 
quently due  to  atmospheric  influences  and  errors  of  diet.  It 
usually  commences  with  simple  or  inflammatory  diarrhoea,  the 
child  loses  its  appetite  and  is  fretful,  then  it  is  seized  w^th  purg- 
mg,  and  occasionally  wnth  .vomiting,  attended  with  prostration, 
pallor,  and  sjanptoms  of  sinking.  Violent  retching  sometimes 
coexist  with  choleraic  diarrhoea,  and  the  disease  may  set  in  very 
suddenly,  and  rapidly  proceed  to  a  fatal  termination.  The  tongue 
is  slightly  coated  or  clean,  smooth,  and  dry,  and  the  pulse  quick 
and  small.  As  the  disease  progresses  the  respiration  becomes 
oppressed,  the  urinary  secretion  is  suspended,  and  the  surface  of 
the  body  is  cold,  damp,  and  sometimes  livid.  The  discharges  at 
first  are  thin  and  fecal,  or  frothy,  with  mucus  or  altered  bile  ;  but 

*■  An  epidemic  of  diarrhoea,  traceable  to  one  special  milk  supply,  is  described  by 
Dr.  Philpot  as  having  occurred  at  Upper  Norwood  in  September,  1877.  The  attack 
was  ushered  in  with  rigors,  pains  in  the  limbs,  and  pyrexia.  The  bowel  discharges 
were  "  of  an  offensive  bilious  character,  going  on  to  mucus,  and,  in  some  instances, 
bloody  stools,  with  tenesmus."  There  was  no  fatal  case,  and  the  disease  yielded  to 
treatment  in  a  few  days. — Medical  Ezaminer,  Jan.  10th,  1878,  p.  29. 

12 


178  DISEASES   OF   CHILDEEX. 

in  the  course  of  a  few  hours  tliere  are  no  traces  of  a  biliary  secre- 
tion whatever,  the  evacuations  being  copious,  frequent,  and  like 
rice-water  or  oatmeal  gruel,  from  containing  shreds  of  intestinal 
epithelium.  It  is  the  excessive  discharges  of  colorless  fluid  which 
distinguish  this  form  of  diarrhoea  from  any  other.  So  great  is  the 
quantity  that  one  evacuation  will  saturate  the  napkins  of  the 
child,  and  completely  soak  through  the  bed  linen,  as  though  they 
had  been  kept  under  water  for  hours.  When  the  stools  are  pale 
and  fluid  there  is  no  odor  belonging  to  them ;  but  if  they  are  in 
any  degree  feculent,  and  yellowish  or  greenish,  then  they  are  ex- 
tremely fetid  and  oflensive,  and,  notwithstanding  the  utmost 
cleanliness,  the  odor  is  at  once  perceptible  on  entering  the  sick- 
apartment. 

At  first  there  are  evidences  of  pain  and  griping  sensations  in 
the  stomach  and  bowels ;  the  hands  and  extremities  are  cold,  the 
face  pinched,  and  the  eyes  hollow.  There  is  usually  a  craving 
thirst,  and  fluids  are  no  sooner  swallowed  than  they  are  brought 
up  again  ;  all  appetite  is  gone,  and  sleep  is  broken  and  unrefresh- 
ing.  If  the  disease  does  not  soon  yield  to  remedies,  the  child  passes 
into  a  state  of  coma  and  dies.  If  the  disorder  lapses  into  a  chronic 
form,  the  evacuations  may  assume  a  dark-greenish  and  putrid 
character ;  the  belly  becomes  tumid  or  tympanitic,  and  the  tongue 
is  covered  with  aphthfe.  The  disease  may  end  fatally  in  a  few 
hours  or  extend  over  some  weeks.  Cases  apparently  hopeless  some- 
times recover. 

The  liver  has  been  observed  to  be  enlarged  in  this  affection  by 
several  writers,  but  the  most  constant  anatomical  change  would 
appear  to  be  enlargement  or  softening  of  Peyer's  patches,  with  an 
erythematous  or  inflammatory  condition  of  the  lining  mucous 
membrane. 

The  following  is  an  example  illustrating  these  several  points :  A 
female  infant,  ten  months  old,  was  seen  by  me  on  July  10th,  1868, 
at  8  A.M.,  having  slept  onlj^  two  hours  during  the  night,  and  not 
at  all  the  day  before.  It  had  been  taken  out  in  the  air,  and  the 
want  of  sleep  attributed  to  being  left  in  the  sun.  The  bowels 
acted  three  times  before  3  o'clock  on  the  preceding  day,  and  again 
at  3  A.M.  next  morning ;  the  last  motion  was  very  watery,  but 
fecal.  On  my  visit  the  child  was  cold,  pinched,  and  collapsed, 
eyes  languid  and  set,  lips  very  blue.  The  child  was  at  once  placed 
in  a  warm  bath,  and  twenty  drops  of  brandy  given  in  some  arrow- 


DIARRHCEA.  179 

root,  which  she  greedily  sucked.  The  circulation  almost  at  once 
returned  in  the  skin  and  lips,  and  she  was  then  taken  out  and  put 
into  a  blanket ;  but  gradually  the  arterial  hue  deserted  the  lips, 
the  surface  of  the  body  was  pale  and  contracted,  and  she  became 
livid  as  before.  She  was  again  placed  in  the  bath,  and  precisely 
similar  symptoms  resulted,  the  color  returning,  and  the  child  as- 
suming a  brighter  asj^ect.  When  removed  from  the  bath  she  as 
quickly  as  before  became  blue  and  collapsed,  but  to  a  somewhat 
less  extent.  A  mixture  of  aromatic  spirit  of  ammonia  and  spirit 
of  chloroform  was  given,  and  a  mustard  poultice  applied  along  the 
spine.  At  11  a.m.  the  child  had  rallied,  and  there  had  been  a  col- 
orless watery  motion  without  a  tinge  of  bile.  The  medicine  and 
beef  tea  were  given  alternately  every  hour.  At  1  p.m.  dilute  sul- 
phuric acid  with  spirit  of  chloroform  was  prescribed  every  second 
hour,  and  at  5  p.m.  the  child  had  rallied,  though  there  had  been 
three  similar  rice-colored  watery  motions,  after  which  more  decided 
collapse  set  in,  and  the  child  expired  with  a  slight  convulsive  seizure 
at  7.45  P.M.     'No  post-mortem  was  allowed. 

4.  Congestive  Inflammatory  or  Mucous  Diarrhoea — Enter o-colitis 
— 3Iuco- enteritis. — In  this  variety  there  is  a  considerable  degree 
of  inflammatory  action,  quickness  of  pulse,  and  constitutional 
disturbance.  The  evacuations  contain  a  large  quantity  of  thin 
mucus,  which  afterwards  becomes  thicker  and  approaches  the 
color  of  pus.  The  motions  are  neither  frequent  nor  excessive ; 
they  are  usually  variable  in  color,  sometimes  being  greenish  and 
offensive  like  chopped  spinach,  and  at  other  times  yellow  and 
mixed  with  mucus.*  Straining  in  going  to  stool  is  a  common  and 
distressing  symptom,  and  more  or  less  blood  is  intimately  mixed 
with  the  mucus  or  fecal  matter. 

Among  the  causes  of  this  form  of  diarrhoea  may  be  enumerated 
damp  and  cold,  and  transitions  of  weather,  but  errors  in  diet  would 
appear  to  be  a  fertile  source  of  its  origin.  If  the  nurse's  milk  is 
too  rich,  or  in  any  way  unhealthy,  it  is  very  likely  to  set  up  diar- 
rhoea in  any  form.     It  may  be  a  sequel  to  choleraic  diarrhoea,  the 


*  "  Dr.  Graves  regards  this  green  matter  as  a  secretion  from  the  mucous  membrane 
of  tlie  small  intestines,  and  not  bile.  Drs.  Simon  and  Golding  Bird  (Medical  Gazette, 
Sept.,  1845)  consider  it  owing  to  blood  which  has  nndergone  a  chemical  change." — 
Quoted  from  Churchill's  Diseases  of  Children,  1848,  p.  533.  Ballard  held  that  it  was 
the  mucus  of  the  gastro-intestinal  canal  acted  upon  by  the  gastric  juice,  and  indicating 
insufficient  or  improper  food.  It  is  often  the  sign  that  weaning  should  be  instituted, 
the  mother's  milk  no  longer  being  a  sufficient  food. 


180  DISEASES    OF   CHILDEEX. 

bowels  remaining  irritable,  and  producing  chronic  inflammatory 
changes  in  the  mucous  membrane,  so  leading  to  gradual  death  by 
exhaustion.  I  quite  agree  with  Meigs  and  Pepper,  who  consider 
that  whether  diarrhoea  is  caused  by  improper  food,  summer  heat, 
dentition,  or  epidemic  influences,  the  complaint,  if  it  becomes 
chronic,  is  apt  to  terminate  in  this  disease.*  It  is  not  unfrequently 
met  with  in  children  in  the  outdoor  department  of  our  hospitals, 
and  I  have  long  been  of  the  opinion  that  the  complaint  is  traceable 
in  them  to  exposure  to  heat  or  cold.  The  cases  we  ordinarily  meet 
with  during  the  summer  are  of  this  character,  and  hence  its  fre- 
quency among  the  children  of  the  poor,  who  are  at  the  same  time 
badly  fed  and  reared  in  an  unhealthy  atmosphere. 

The  cutting  of  the  teeth  may  exert  an  influence  in  causing 
diarrhoea,  as  it  does  in  setting  up  irritation  in  the  brain  and  other 
organs.  It  is  common  between  the  ages  of  six  months  and  two 
years,  when  the  first  dentition  is  completed.! 

The  disease  may  be  acute  or  chronic.  In  the  first  form  the 
symptoms  are  active  from  the  first,  inflammatory  products  passing 
oti'  from  the  intestines,  and  the  disease  seldom  lasting  more  than 
a  week  or  ten  days.  The  chronic  form  of  the  disorder  may  con- 
tinue for  weeks  or  months ;  there  is  a  gradual  loss  of  flesh  and 
strength,  and  the  bowels  are  perpetually  acting. 

The  morbid  appearances  are  a  thickening  or  inflammation  of  the 
intestinal  mucous  membrane,  which  becomes  red  or  of  a  darkish- 
graj^  hue,  with  the  evidence  of  ulceration  or  enlargement  of  the 
glandular  follicles  lining  the  colon  and  small  intestine. 

Muco-enteritis  ma}'  follow  an  attack  of  measles,  pneumonia, 
whooping-cough,  or  typhoid  fever.  It  is  prone  to  attack  feeble 
and  delicate  children  of  strumous  constitution.  The  abuse  of 
aperient  medicines  may  induce  a  simple  diarrhoea  which  passes 
into  this  form,  and  weaning,  or  the  change  of  a  nurse  is  another 
cause.  The  morbid  anatomy  of  the  aflection  shows  disease  of  both 
the  large  and  small  intestines.  In  the  large  intestine,  the  sig- 
moid flexure  and  descending  colon  are  chiefly  aflected  ;  in  the 
small  intestine  the  lower  part  of  the  ileum.     In  the  acute   stage, 

*  Diseases  of  Children,  otli  edition,  1874,  p.  3S4. 

t  "The  greatest  prevalence  of  diarrhcea  coincides  exactly  with  that  time  whilst  the 
process  of  dentition  is  going  on  most  actively,  and  that  exactly  half  of  all  cases  of 
diarrhoea  occurred  in  children  between  the  ages  of  six  months  and  two  years." — West, 
on  tbi  Discuses  of  Infancy  and  Childhood,  1859,  p.  587. 


DIAERHGEA.  181 

the  mucous  membrane  of  the  intestine  is  increased  in  vascularity 
and  softened. 

Thermic  diarrhoea  is  the  form  met  with  in  summer  and  espe- 
ciall}''  in  hot  climates.  It  has  been  well  described  by  Dr.  C.  G. 
Comegys  and  Dr.  H.  C.  Wood.  It  may  be  designated  "  thermic 
or  heat  diarrhoea."  "Any  one  who  has  seen,"  says  Dr.  Wood, 
"  as  I  have  this  summer,  the  child  on  whom  drugs  had  ceased 
to  act,  and  who  was  seemingly  doomed  to  die,  relieved  in  twelve 
hours  by  enforced  cold  bathing,  every  three  or  four  hours,  will 
grant  to  Dr.  Comegys  the  credit  of  having  introduced  one  of  the 
most  life-saving  improvements  in  modern  infantile  therapeutics. 
The  sudden  sweet  sleep,  replacing,  after  the  bath,  the  fretful 
nights  and  days  of  unrest,  is  a  thing  never  to  be  forgotten  when 
once  seen,  and  the  arrest  of  diarrhoea  is  certainly  no  less  remark- 
able."* 

"  We  are  summoned,  in  short,  very  often  to  see  a  child  with  a 
hot  skin  (temperature  102^°-105°),  rapid  pulse  (130-150)  and 
breathing  (30-40),  with  frequent  purging  of  semifluid,  greenish, 
watery,  fecal,  and  half-digested  matters;  the  mouth  and  tongue 
are  dry,  the  thirst  is  intense,  but  the  water  given  to  appease  it  is 
quickly  thrown  off,  the  eyes  are  staring,  pupils  contracted, 
insomnia,  rolling  the  head,  and  uttering  distressing  cries,  due  to 
the  headache  from  hyperpemia  of  the  cerebral  vessels  and  the  un- 
appeased  thirst."  The  bath  is  first  at  the  summer  temperature  of 
75°,  the  feet  and  legs  are  first  gradaally  immersed,  and  then  water 
is  poured  over  the  chest  and  abdomen  till  the  whole  body  is  under 
water.  Colder  water  (65°)  is  then  poured  in  a  continuous  stream 
over  the  upper  part  of  the  head,  and  this  is  kept  up  for  fifteen 
minutes.  When  the  child  is  removed  from  the  bath  it  is  wrapped 
in  a  woollen  shawl,  and  placed  in  bed  with  additional  covering. 
It  falls  asleep,  the  skin  is  cool,  the  pulse  and  respiration  fall  in 
frequency,  and  the  temperature  is  at  or  below  the  normal  standard. 
If  the  symptoms  return  the  bath  may  be  resumed  three  or  four 
times  a  day.  The  internal  treatment  consists  in  giving  beef  tea, 
milk,  and  lime-water ;  "  one  grain  of  quinine  and  a  half  to  a  tea- 
spoonful  of  whiskey  every  three  hours  for  a  child  eight  to  sixteen 
months   look   formidable,  but    they    will    be   borne   admirably." 

*  Sunstroke  or  Thermic  Fever,  by  Dr.  H.  C.  Wood,  Philadelphia  Medical  Times, 
A.ugust  5th,  1876,  p.  542. 


182  DISEASES    OF    CHILDREN. 

Witli  tlie  departure  of  the  fever,  bismutli  and  pepsin  are  given 
to  restrain  diarrhoea  and  assist  digestion."^' 

5.  Lienteric  Diarrhoea. — This  form  of  diarrhoea,  known  as 
lientery,  is  characterized  by  the  passage  of  undigested  food 
through  the  bowels ;  it  is  very  commonly  seen  in  artificially 
reared  children,  especially  among  those  who  are  subject  to  mesen- 
teric disease.  Food  which  they  cannot  assimilate  passes  through 
them.  Meat,  or  bad  milk,  or  vegetables,  on  which  the  gastric 
juice  has  no  action,  pass  through  the  stomach,  setting  up  irrita- 
tion in  the  bowels.  The  food  undergoes  scarcely  any  change  in 
its  passage  through  the  long  and  tortuous  length  of  the  alimen- 
tary canal.  Shortly  after  eating  the  child  experiences  discomfort, 
and  passes  the  meat,  which  has  just  been  previously  taken,  with- 
out the  secretion  of  the  stomach  having  exerted  a  solvent  action 
upon  it.  It  is  probable  that  the  stomach  is  feeble  and  primarily 
at  fault  in  so  rapidlj^  dislodging  its  contents.  The  child's  appetite 
is  greedy  and  never  satisfied  ;  there  is  great  debility  and  loss  of 
flesh,  because  the  food  is  not  absorbed,  and  there  is  thirst  and 
general  irritability. 

Dyf^enleric  DiarrlvEa. — When  the  discharge  of  mucus  from  the 
bowels  is  excessive,  and  is  attended  with  a  considerable  quantity 
of  blood  also,  and  there  is  no  fever,  we  may  recognize  this  form. 
It  is  not  exactly  one  of  acute  or  chronic  dysentery,  but  of  great 
congestion  of  the  intestinal  vessels,  leading  to  their  rupture. 
There  are  feculent  discharges,  with  tenesmus,  pain  in  the  body, 
and  wasting,  and  the  child  loses  flesh  rapidly.  Dysentery  may  be 
described  as  a  severe  form  of  muco-enteritis,  with  more  pain  than 
is  felt  in  diarrhoea. 

Chronic  Diarrhea. — This  form  may  be,  and  often  is,  the  conse- 
quence of  the  acute  forms  passing  into  it  by  slow  degrees,  or  it 
may  follow  cold  and  overfteding,  the  use  of  sour  milk,  or  the 
milk  of  a  w^et-nurse  which  is  in  all  respects  apparently  healthy. 
The  continued  discharges  from  the  bowels  gradually  reduce  the 
strength  and  impair  the  powers  of  nutrition.  A  chronic  state  of 
irritation  or  catarrh  is  induced,  and  the  longer  it  lasts  the  more 
diflicult  will  it  be  to  control.  In  this  form  of  the  disease  the  mo- 
tions are  variable,  sometimes  being  copious  and  at  other  times  quite 


*  Cool  Batliing  in  tlie  Treatment  of  Inflammatory  Bowel  Affections  during  the 
Summer,  by  C.  G.  Comegys,  M.D.,  Pluladelphia  Medical  Times,  July  17th,  1875,  p- 
605. 


DIAEEHCEA.  183 

thin  and  slimy,  with  gelatinous  masses  of  mucus  streaked  Avith 
blood.  As  we  have  seen  in  the  disease  known  as  '•'•Ikniery^''  any 
undigested  food  in  the  motions  is  significant  of  feeble  digestive 
power  and  impaired  nutrition ;  the  milk  or  other  articles  of  diet 
pass  through  the  stomach  rapidly,  and  in  many  cases  there  is  a 
deficiency  of  bile. 

Causes  of  Diarrhcea. — In  most  cases  diarrhoea  is  the  consequence 
of  improper  feeding.  A  very  common  cause  is  the  habit  of  giving 
young  children  farinaceous  or  biscuit  food  instead  of  milk,  especi- 
ally if  the  child  is  delicate  or  rickety.  The  stomach  is  easily 
deranged,  and  the  unhealthy  products  of  digestion  entering  the 
intestinal  canal  excite  irritation  till  they  are  eliminated.  So  far, 
it  is  a  salatarj''  process,  and  the  diarrhcea  may  soon  pass  off.  Since 
the  use  of  feeding-bottles  has  become  general,  diarrhoea  is  easily 
provoked  if  they  are  not  properly  cleansed  and  rinsed  out.  When 
this  precaution  is  neglected,  any  fresh  milk  that  may  be  put  in 
turns  sour  and  acid.  It  may  be  induced  by  unhealthy  nurses 
whose  milk  is  deranged  through  privation  or  anxiety,  or  when 
they  are  suftering  from  leucorrhoea.  Impure  water,  bad  air,  filth 
and  overcrowding,  are  also  to  be  enumerated  among  the  chief 
causes  of  the  com. plaint.  Exposure  to  cold  or  heat,  and  biliary  de- 
rangement may  all  lead  to  the  disorder.  Very  troublesome  diar- 
rhoea may  sometimes  be  witnessed  in  children  at  the  time  of 
weaning.  The  child  has  probably  become  badly  nourished  from 
the  mother  suckling  it  till  it  is  a  year  old,  and  then  the  change  of 
diet  to  corn  flour,  mashed  potatoes,  bread  and  butter,  and  even  a 
little  meat,  will  cause  relaxation  of  the  bowels,  restlessness,  and 
thirst ;  five  or  six  motions  will  escape  during  the  day,  slimy  and 
containing  spots  of  blood.  Only  a  change  of  diet  can  set  matters 
right. 

Diarrhoea  is  sometimes  noticed  in  connection  with  rickets,  and 
it  very  frequently  follows  whooping-cough  and  measles. 

Troublesome  diarrhoea  may  be  kept  up  by  the  indiscriminate 
use  of  aperient  medicines. 

Treatment. — This  will  depend  upon  the  cause,  which  should  be- 
if  possible  ascertained.  But  whatever  may  be  the  origin,  and 
whatever  the  variety  or  stage  of  the  disorder,  the  diet  will  require' 
immediate  and  careful  attention.  ISTothing  can  be  done  towards, 
eftecting  a  cure  till  the  age  and  constitution  of  the  child  are  con- 
sidered, and  it  should  be   particularly   noticed   whether  it  has- 


\ 


184  DISEASES    OP   CHILDREN.  . 

become  suddenly  or  gradually  ill ;  this  question  is  of  immense 
importance  in  the  plan  of  treatment  to  be  pursued.  If  the  child 
has  no  teeth,  corn-flour,  and  farinaceous  food  of  all  kinds  must  be 
forbidden,  and  milk  in  some  shape  be  relied  upon.  If  the  child  is 
an  infant,  and  artificially  reared,  a  tablespoonful  or  two  of  lime- 
water  should  be  mixed  with  each  bottle  of  milk,  and  this  will  aid 
the  digestion  of  it  and  prevent  it  turning  sour.  If  there  is  much 
sickness,  it  may  be  necessary  to  apply  a  small  mustard  poultice  to 
the  pit  of  the  stomach,  to  suspend  the  milk  for  a  time,  and  to 
give  barley-water  in  its  place,  and  a  teaspoonful  of  cold  water 
occasionally.  Too  much  stress  cannot  be  laid  on  the  importance 
of  feeding,  and  of  selecting  the  purest  milk.  When  every  pre- 
caution has  been  taken  with  .the  bottle,  in  the  way  of  cleanliness, 
I  have  known  the  diarrhosa  continue,  or  the  bowels  to  remain 
quiet  one  day  and  the  discharges  to  be  healthy,  and  jet  griping 
pain,  exhausting  diarrhoea,  and  sickness  to  follow  next  day.  The 
bottle  is  abandoned  in  consequence,  and  the  child  is  fed  with 
diluted  cow's  milk  in  a  teaspoon,  and  forthwith  the  diarrhoea 
ceases.  In  some  cases  Swiss  milk  has  occssionally  succeeded  better 
than  cow's  milk,  and  that  when  one  wet-nurse  after  another  has 
failed.* 

The  simple  form  of  diarrhoea  is  consequent  upon  irritation  of 
the  lining  membrane  of  the  bowels  in  the  majority  of  cases, 
and  therefore  it  is  not  prudent  to  hastily  check  it,  as  it  is  an 
effort  on  the  part  of  nature  to  expel  offending  matters  from  the 
system ;  if  after  a  time  the  diarrhoea  continues,  a  morbid  action 
of  the  mucous  membrane  is  kept  wp,  which  demands  remedies  to 
control  it.  If  it  appears  to  arise  from  irritation  in  the  stomach 
or  bowels,  a,  teaspoonful  of_  castor  oil,  or  a  few  grains  of  soda 
and  rhubarb,  will  soon  arrest  the  symptoms  and  the  child  will  feel 
no  further  trouble.  In  that  variety  of  diarrhoea  where  there  is 
straining  with  mucus,  or  mucus  with  blood,  a  paste  of  castor  oilf 
and  magnesia,  with  a  carminative  will  be  very  useful.    If  there  is 

*  See  Chapter  II. 
t  Formula  23: 

B.  01.  ricini, 5ss. 

Magnes.  carb., gij 

Sacchari,        .  .........     ^iij 

01.  anisi, "Jlij.— M. 

A  teaspooful  for  a  dose.     (An  infant  may  take  a  dose  occasionally.)     For  children 
from  six  io  twelve  months  old. 


DIAREHCEA.  185 

griping  pain,  and  the  diarrhoea  is  profuse,  the  addition  of  half  a 
minim  of  laudanum  will  be  serviceable.*  Castor  oil  possesses  mild 
and  unirritating  qualities,  and  promotes  the  escape  of  fluid  secre- 
tions from  the  intestinal  canal  without  pain  or  discomfort.  This 
being  accomplished,  its  subsequent  action  is  said  to  be  astringent, 
so  that  at  the  commencement  it  is  probably  the  safest  and  best 
eliminator  of  morbid  secretions  which  excite  the  irritation  of  the 
bowel. 

When  the  diarrhoea  is  acute  and  recent,  soothing  and  unirri- 
tating diet  is  especially  to  be  recommended,  rice-water  flavored 
with  cinnamon,  or  barley-water,  so  that  the  intestines  may  have 
all  possible  rest.  Sago,  tapioca,  corn-flour,  arrowroot,  and  chicken 
broth,  are  all  ai;ticles  of  diet  to  be  borne  in  mind.  In  older  chil- 
dren, where  the  diarrhoea  appears  to  depend  on  congestion  of  the 
mucous  membrane,  a  combination  of  gray  powder  and  Dover's 
powder  will  be  useful  for  a  few  nights,  with  bismuth  mixture 
during  the  day.f  I  have  seen  excellent  results  from  this  plan  of 
treatment  in  out-patient  practice,  even  when  the  children  have 
not  been  confined  to  the  house.  The  treatment  of  summer  diar- 
rhoea has  already  been  considered. 

The  treatment  of  diarrhea,  particularly  in  teething  children,  is 
apt  to  be  looked  at  with  a  one-sided  .view, — the  quickest  way  to 
stop  the  diarrhoea.  This  is  a  fatal  mistake.  If  the  child  is  of 
full  habit  with  florid  face  and  greedy  with  its  food,  it  is  not  a 
good  plan  to  hastily  cheek  the  diarrhoea,  but  we  should  simply 
moderate  the  alvine  losses  by  some  alkaline  mixture ;  and  if  there 
are  any  teeth  pressing  against   the  gums,  the   latter  should  be 

*  Formula  24 : 

R.  01.  ricini, §ss. 

T.  opii, "jjvj 

Mucilag., 3ij 

Syr.  zingib., ^iij 

Aquam  anethi  ad ,^iss. — M. 

One  teaspoonful  to  be  given  occasionally.     For  children  from  six  to  twelve  months 
old. 

t  Formula  25 : 

R.  Sodae  bicarb., gr.  xij 

Liq.  bismuth., 3'j 

Mucilag., 3ij 

Syr.  zingib.,  .         .         .         .         .         .         .         .         ,  .^ss. 

Liq.  magnes.  carb.,       ........  .^iv. — M. 

A  dessertspoonful  three  times  a  day.     For  a  child  two  years  old. 


186  DISEASES    OF    CHILD  REX. 

scarified  or  well  incised.  Very  often  the  general  disturbance  and 
intestinal  disorder  yield  at  once  to  these  remedies.  Speaking  of 
the  diarrhoea  arising  from  improper  food  or  teething,  Dr.  Pavy 
writes:  "  I  am  in  the  habit  of  giving,  and  with  the  most  satisfactory 
result,  a  little  ipecacuanha  with  a  bitter  and  a  saline.  My  prescrip- 
tion consists  of  a  few  minims  of  the  vinura  ipecacuanha,  twenty 
minims  or  so  of  the  tincture  of  calumba,  and  one  or  two  or  three 
drachms  of  the  Mistura  Saliua  of  the  Guj^'s  Pharmacopoeia,  which  is 
made  by  saturating  a  solution  of  carbonate  of  potash,  containing 
twenty  grains  of  the  carbonate,  to  each  liuid  ounce  of  water,  with 
lemon-juice.  Conjoined  with  this  a  couple  of  grains  of  gray 
powder  are  sometimes  given  as  an  alterative  everj'  morning  ;  or 
sometimes  a  powder  consisting  of  a  quarter  or  half  a  grain  of 
calomel,  two  grains  of  the  dried  carbonate  of  soda,  and  five  grains 
of  the  aromatic  powder  of  chalk."*  The  formula,  recommended 
by  Dr.  West,  containing  small  doses  of  vinum  ipecacuanh^e  and 
liquor  potass^e,  is  also  very  useful  f 

As  a  rule,  astringents  are  objectionable  at  an  esLvly  stage  of 
diarrhoea,  which  may  continue  in  spite  of  them  unless  other  pre- 
cautions are  taken.  If  tbe  motions  contain  mucus  and  are  slimy, 
and  there  is  an}-  escape  of  blood,  or  redness  about  the  anus,  chalk 
mixture,  catechu,  acids,  or  bismuth,  will  be  of  no  service ;  but  in 
their  stead  the  remedies  we  have  already  pointed  out,  especially 
the  castor  oil  paste  and  alkalies,  with  an  alterative  or  sedative,  as 
the  case  may  appear  to  warrant. 

The  diet  is  primarilj^  at  fault  in  these  cases,  undigested  food 
having  passed  into  the  bowels,  and  having  excited  over-activity 
of  their  functions.  Warmth  and  the  most  complete  rest,  with  a 
dose  of  castoi*  oil,  is  the  most  appropriate  treatment,  and  a  grain  of 
Dover's  powder  with  a  grain  of  gra^^  powder  maj-  be  necessary. 
Xow  and  then  a  quarter  of  a  grain  of  calomel  will  be  found  of  use 
in  children  who  are  old  enough  and  strong  enough  to  bear  it. 

Among  hospital  patients,  a  large  number  of  cases  of  diarrhoea 
are  traceable  to  oversuckling,  and  suckling  by  mothers  in  delicate 
health,  or  harassed  hy  anxiety.  The  return  of  the  catamenia  or 
even  menorrhagia  is  no  hindrance  to  the  habit.  If  such  children 
are  removed  from  the  breast,  and  cows'  milk  is  given  diluted  with 
water,  previously  warmed  and  sweetened,  the  diarrhoea  will  gener- 

*  Digestion  and  its  Disorders,  18G7,  p.  199. 
t  Oj>.  cit.,  p.  524. 


DIAEEHCEA.  187 

ally  subside.  AVlien  milk  appears  to  keep  up  the  diarrhoea,  barley- 
water,  or  cold  water  thickened  with  isinglass  will  be  necessary,  or 
thin  water  arrowroot.  Sometimes  a  powder  containing  two  or 
three  grains  of  rhubarb  and  carbonate  of  soda  will  neutralize  the 
acidity  which  has  resulted  from  the  fermentative  products  of  di- 
gestion and  soon  arrest  the  disorder.* 

In  some  cases  where  a  child  is  strong,  and  where  there  is  no  ab- 
dominal pain,  the  motions  containing  mucus  or  blood,  a  mixture 
of  sulphate  of  magnesia,  tincture  of  rhubarb  and  peppermint- 
water  may  bia  prescribed  with  advantage. f 

As  to  stim.iilants,  if  there  is  much  exhaustion  a  few  drops  of 
brandy  (and  there  is  no  better  stimulant)  in  weak  arrowroot  or 
milk  are  advisable,  and  if  there  is  much  sickness,  a  mustard  poul- 
tice to  the  epigastrium.  A  teaspoon ful  of  cold  or  iced  water  will 
often  allay  the  sickness.  Wine  whey  (one  part  of  wine  to  three 
of  boiled  milk)  is  useful  where  the  child  is  exhausted,  and  life  may 
sometimes  be  saved  by  it.  • 

In  the  treatment  of  bilious  diarrhosa,  alkalies,  especially  soda 
salts,  should  be  given  to  relieve  acidity,  with  one  or  two  minims 
of  laudanum,  if  there  be  much  pain.  An  occasional  mild  mer- 
curial is  also  serviceable. 

Treatment  of  Cholera  Infantum. — In  the  whole  catalogue  of  in- 
fantile disorders  there  is  no  disease  requiring  greater  vigilance 
and  care.  Any  error  of  judgment  is  speedily  fatal.  The  child 
should  be  confined  to  a  spacious  airy  room,  and  the  utmost  quie- 
tude observed.  When  the  bowel  discharges  are  profuse  and  watery, 
and  the  child's  strength  is  good,  a  dose  of  castor  oil  or  rhubarb 
may  be  advisable,  because  the  choleraic  poison,  or  other  otlending 

*  Formula  26 : 

R.  Pulv.  rhei, 

Sodse  bicarb.,  aa        .......         .     gr.  xij 

Spt.  anim.  aroni.,       .         .         .• n^xx 

Syr.  zingib., ^iij 

Aqiiam  menth.  pip.  ad giss. — M. 

A  teaspoonful  every  four  hours.     For  children  a  year  old. 
f  Formula  27  : 

B.  Magn.  sulph., ^j 

Tinct.  rhei, 3j 

Vel  syr.  rhei, ^^ij 

Tinct.  quinice,    .         .         .         .         .         .         .         .         .     ,^ss. 

A*quani.  menth.  pip.  ad ^iss. — M. 

A  teaspoonful  every  four  hours.     For  children  a  year  old. 


188  DISEASES   OF   CHILDREN. 

materials,  will  keep  np  the  intestinal  discharges,  as  long  as  thej 
remain  pent  up  in  the  system.  Elimination  through  the  bowels, 
consistent  with  the  strength  of  the  child,  is  therefore  a  rational 
mode  of  treatment. 

After  this,  it  is  well  to  moderate  the  drain,  if  the  child's  strength 
fails,  b}'  krameria,  or  one  or  two  drops  of  laudanum  (Form.  15), 
and  the  treatment  continued,  or  modified,  according  to  circum- 
stances. If  looseness  of  the  bowels  goes  on  unchecked,  it  becomes 
a  diseased  and  not  a  carative  process. 

When  there  is  vomiting,  I  have  given  prussic  acid' in  combina- 
tion with  a  drop  or  two  of  laudanum,  or  the  solution  of  muriate 
of  morphia;  but  too  frequently  nothing  has  arrested  the  sickness. 
It  is  in  these  cases  that  dilute  sulphuric  acid  has  been  recom- 
mended (Form.  34).  The  fact  of  vomiting  ought  not  to  discourage 
a  plentiful  supply  of  cold  water,  in  very  small  quantities  at  a  time, 
or  toast-water  to  alleviate  the  thirst.  If  indeed  the  retching  is 
distressing  and  urgent,  a  drink  of  tepid  water,  by  facilitating  the 
escape  of  morbid  secretions  from  the  stomach,  is  a  rational  plan 
to  try.  In  this  way  the  vomiting  and  purging  may  be  arrested 
in  many  cases  that  appear  almost  hopeless. 

As  long  as  there  are  offensive  matters  in  the  bowels,  it  must  be 
our  endeavor  to  get  rid  of  them,  as  their  retention  in  the  body  in- 
creases the  mischief,  and  therefore  opium  and  its  2:)reparations 
should  be  given  with  great  caution. 

When  the  disease  has  passed  into  the  stage  of  collapse,  there  is 
an  impediment  to  the  circulation  through  the  lungs,  and  the  reme- 
dies for  exhaustion,  as  stimulants  and  opiates,  generally  fail  to 
aftbrd  relief.  The  body  must  be  kept  warm  with  flannel  or  the 
warm  bath,  cramps  relieved  by  friction,  and  a  few  minims  of  sal 
volatile  or  chloric  ether  administered.  If  it  is  considered  advisable 
to  employ  a  warm  bath  to  encourage  reaction,  the  temperature 
should  not  exceed  95°  Fahr. ;  the  child  should  not  be  suddenly 
immersed,  but  a  blanket  should  be  laid  over  it,  and  then  the  child 
being  also  well  protected  with  flannel,  can  be  gradually  let  down 
into  the  water  without  causing  any  alarm. 

Dr.  George  Johnson  attributes  the  collapse  in  cholera  to  spasm 
of  the  arterioles  of  the  pulmonary  artery  from  an  alteration  in  the 
blood,  but  this  does  not  appear  to  me  quite  a  satisfactory  expla- 
nation of  the  phenomena,  when  we  remember  there  are  conditions 
allied  to  this  form  of  collapse  in  which  the  blood  cannot  be  said  to 


DIAEEHCEA.  189 

have  undergone  a  poisoned  state,  or  tlie  lungs  to  be  specially  im- 
plicated. On  the  other  hand,  some  drugs  in  poisonous  doses,  and 
some  animal  and  vegetable  substances  have  exerted  such  an  irri- 
tating action  on  the  stomach  and  intestines  as  to  produce  symp- 
toms resembling  cholera  collapse.*  The  calibre  of  the  vessels  may 
be  influenced  by  the  sympathetic  nerve  throughout  the  alimen- 
tary canal,  and  paralysis  of  the  vasomotor  nerves  would  produce 
dilatation  and  relaxation  of  the  vessels,  the  child  being  thus  bled 
as  it  were  into  its  own  veins,  and  watery  discharges  are  the  con- 
sequence. 

When  reaction  is  established,  a  few  drops  of  brandy  are  useful, 
chicken  broth,  milk,  and  the  mineral  acids  are  serviceable. 

Calomel  is  scarcel}^  to  be  thought  of  in  these  cases,  for  fear  of 
increasing  the  general  depression.  If  it  is  ever  advisable  it  should 
be  confined  to  the  early  stage  where  the  motions  are  fecal,  and 
never  had  recourse  to  where  the  discharges  are  watery  and 
serous,  for  fear  of  increasing  the  gastro-intestinal  irritation.  Wie- 
meyer  seems,  however,  to  have  used  it  successfully,  and  Dr.  Lewis 
Smith  has  seen  advantage  follow  a  fractional  part  night  and  morn- 
ing with  opium  and  astringents.  "  For  cholera  infantum,  if  seen 
early,  give  a  hypodermic  injection  of  morphia  of  suitable  dose,  to 
be  followed  up  with  small  doses  of  calomel  and  camphor  in  sugar 
of  milk,  until  biliary  dejections  are  seen."  (Comegys.)  This  seems 
to  me,  however,  a  very  hazardous  measure. 

In  the  treatment  of  dysenteric  diarrhoea,  Dr.  de  Havilland  Hall 
advises  one  or  two  grains  of  ipecacuanha  three  times  a  day,  and 
though  sickness  may  at  first  be  produced,  tolerance  is  soon  estab- 
lished, f 

Treatment  of  Chronic  Diarrhosa. — If  the  diarrhcea  occurs  in  an 
infant  it  should,  if  suckling,  be  limited  to  the  breast,  and  no  other 
food  be  given  whatever,  unless  circumstances  of  a  grave  character 
should  arise,  and  then  it  may  be  necessary  to  suspend  nursing  for  a 
time,  and  give  barley-water,  thin  veal  broth,  etc.  Then,  too,  the 
milk  of  one  nurse  will  keep  up  diarrhoea,  when  that  of  another  will 
be  easily  digested  ;  and  it  will  not  unfrequeutly  be  found  that  one 
nurse  after  another  will  fail  to  supply  suitable  nourishment  to  the 
child,  till  we  have  to  fall  back  upon  plain  milk  and  water.     If  this 

*  On  some  Analogies  of  Cholera,  etc.,  Med.-Chir,  Trans.,  1868,  vol.  ii,  p.  1,  by  W. 
Sedgwick,  M.K.C.S.E. 

f  St.  Barth.  Hosp.  Repts.,  vol.  xi,  p.  273. 


190  DISEASES   OF   CHILDREN. 

does  not  succeed,  condensed  milk  sboiild  be  tried,  as  I  have  pre- 
viously mentioned.  The  microscope  may  detect  nothing  wrong  in 
the  milk  of  the  nurse,  and  yet  it  may  cause  the  most  violent 
irritation.  Where  milk  disagrees  to  such  an  extent  as  this,  it  is 
obvious  that  some  other  means  must  be  adopted  for  a  time  to  sup- 
port the  child.  For  children  who  ha-ve  reached  five  or  six  months 
old,  veal  broth,  or  weak  beef  tea,  or  raw  meat  juice,  may  be  tried, 
if  the  milk  appears  to  keep  up  irritation.  As  the  child  grows  older 
it  will  be  able  to  digest  better,  and  then  the  discretion  of  the 
practitioner  must  be  used,  and  the  diet  varied  according  to  cir- 
cumstances. As  long  as  the  stools  are  unhealthy,  or  pasty,  all 
farinaceous  food  must  be  given  with  caution,  as  it  will  frequently 
pass  through  the  stomach  undigested. 

Too  much  importance  cannot  be  attached  to  the  food.  It  is  of 
the  highest  consideration  that  it  should  be  pure,  nutritious,  and 
unirritating.  Where  there  is  defective  nutrition  the  child  will 
gradually  waste,  and  the  more  exhausted  it  becomes,  the  more 
difficult  will  it  be  to  overcome  the  diarrhosa,  which  is  prone  to  go 
on  in  spite  of  all  the  pharmaceutical  remedies  in  vogue.  Hence  it 
is  that  raw  meat  juice  sometimes  answers  so  well  in  these  cases. 
It  may  be  made  of  beef,  or  mutton.* 

*  "  Take  a  quarter  of  a  pound  of  the  best  rump  steak,  gravy  meat,  or  reddish  buttock 
meat ;  cut  it  in  very  minute  piece*,  so  as  to  make  the  finest  jaossible  mince  of  it,  as  fine 
as  cut  up  spinach.  Tiiis  is  best  done  by  a  sausage  machine,  then  add  water  to  the  brim. 
If  there  be  time  to  wait,  this  water  may  be  cold  ;  if  not,  it  should  be  lukewarm,  oi-,  at 
least,  not  exceeding  a  temperature  of  120°  Fahr.  Stir  up  frequently  with  a  spoon.  At 
the  end  of  two  or  three  hours  the  supernatant  water  will  have  the  color  of  dark  claret^ 
The  meat  at  the  bottom  will  have  become  as  white  as  fish.  Strain  through  a  coarse 
sieve.  Drink  the  juice  cold — about  a  claretglassful  three  times  a  day." — On  Infant 
Feeding,  by  C.  H.  F.  Routh,  M.D.,  3d  edit.,  p.  335. 

''Take  one  pound  of  fresh  beef,  free  from  fat,  chop  it  up  fine,  and  pour  over  it  eight 
ounces  of  soft  water,  add  live  or  .six  dro{,)s  of  hydrochloric  acid  and  fifty  or  sixty  grains 
of  common  salt,  stir  it  well,  and  leave  it  for  three  hours  in  a  cold  place.  Then  pass  the 
fluid  through  a  hair  sieve,  pressing  the  meat  slightly,  and  adding  gradually  towards 
the  end  of  the  straining  about  two  more  ounces  of  water.  The  liquid  thus  obtained  is 
of  a  red  color,  possessing  the  taste  of  soup.  It  should  be  taken  cold,  a  teacupful  at  a 
time.  If  preferred  warm,  it  must  not  be  put  on  the  fire,  but  heated  in  a  covered  vessel 
placed  in  hot  water  Should  it  be  undesirable  for  the  patient  to  take  the  acid,  this 
soup  may  be  made  by  mei'ely  soaking  the  minced  beef  in  distilled  water." — Handbook 
of  Therapcutlrs,  by  S.  Ringer,  ]\1.D.,  4th  edit.,  p.  610. 

"A  piece  of  the  lean  of  mutton  should  be  minced,  poimded  to  a  pulp,  and  all  fibrous 
threads  carefully  removed.  To  insure  its  fine  division  and  complete  separation  from 
indigestible  fibre,  it  is  useful  to  have  it  rubbed  through  a  sieve.  The  pulp,  duly  mixed 
with  breadcrumbs  and  salt,  may  be  given  in  a  daily  quantity  of  from  one  to  three 
ouncGF,  according  to  the  age  of  the  child.     This  is  particularly  called  for  when  the 


DIAREHCEA.  191 

With  reorard  to  drno's,  it  should  be  remembered  that  there  is  a 
great  tendency  to  acidity  of  the  secretions ;  excess  of  acid  in  the 
stomach  retards  the  digestive  power,  excites  fermentation,  and 
causes  flatulence,  pain,  and  irritation,  so  that  the  child  is  never 
easy,  and  can  obtain  no  rest.*  Potash,  by  neutralizing  the  acidity, 
arrests  the  fermentative  process,  and  it  may  be  given  with  dill, 
aniseed,  or  cinnamon-water,  three  or  four  times  a  day  after  feed- 
ing. If  the  stools  are  thin  a  mixture  of  bismuth  and  potash,  or 
soda  may  be  given  (Form.  25).  As  long  as  the  motions  are  acrid 
and  offensive  one  of  these  remedies  should  be  prescribed.  Some- 
times a  grain  of  ITyd.  c.  Creta  may  be  most  advantageously  added 
to  a  powder  of  soda  and  rhubarb.  Ipecacuanha  in  doses  of  a 
quarter  of  a  grain,  with  the  castor  oil  mixture  and  laudanum 
(Form.  24),  is  an  excellent  remedy,  particularly  in  the  dysenteric 
variety.  Creasote  has  been  employed  successfully  where  the  mo- 
tions are  frothy  and  fetid.  A  chronic  diarrhoea  is  cured  or  kept 
in  check  by  gallic  acid  or  acetate  of  lead,  recommended  by  Dr. 
"West  (Form.  28,  29). f    Some  of  the  following  mixtures  containing 

motions  contain  a  large  proportion  of  unaltered  food.     Under  this  invaluable  remedy 
the  state  of  the  bowels  and  of  the  general  health  often  improves  at  once  and  together. 
Occasionally,  in  chronic  diarrhoea,  I  have  seen  benefit  from  the  extract  of  malt." — On 
Infantile  Diarrhoza,  by  W.  H.  Dickinson,  M.D.,  Medical  Times  and  Gazette,  September, 
1872,  p.  256. 

*  See  Chapter  XIV,  "On  Indigestion." 
f  Formula  28 : 

R.  Acid,  gallic,        .........     gr.  viij 

Tinct.  cinnam.,    .         .         .         .         .         .         .         .         •     .oj 

Tinct.  opii,  .........  "J^iv 

Syrupi, 3ij 

Aquje  cinnamomi,       .         .         .         .         .         .         .         •  3^' 

Aquam  ad  .........  5ij. — M. 

Two  teaspoonfuls  everv  four  hours. 
Formula  29 : 

R.  Plumbi  acetat,   .         .         .         .         .         .         .         .         .  gr.  vj 

Aceti, nj^xx 

Tinct.  opii,  .........  "Xviij 

Mucilag.  acacise, oij 

Syr.  zingib., oj 

Aquam  ad  .........  51,). — M. 

Two  teaspoonfuls  every  six  hours. 
Formula  30 : 

R.  Tinct.  opii, "jjyj 

Tinct.  card,  co.,  ........  .5.) 

Syrupi, ,         .         .  gij 

Decoct,  hffimatoxyli  ad      ......         .  o'°^- — •^^• 

A  teaspoonful  every  four  hours. 


192 


DISEASES    OF    CHILDREJST. 


logwood  (Form.  30),  cateclin,  and  chalk  (Form.  31),  krameria 
(Form.  32),  nitric  acid  (Form.  33),  or  sulphuric  acid  (Form.  34), 
with  bark  or  chloric  ether,  may  all  prove  useful  in  turn.  Sulphuric 
acid,  however,  whether  combined  with  an  aromatic  or  sedative  has 


Formula  31 : 

R.  Tinct.  catechu 

Syr.  zingib.,        ...... 

Mist,  cretse  ad    .....         • 

A  teaspoonful  every  four  hours. 
Formula  32 : 

R.  Tinct.  kramerise,         ..... 

Tinct.  opii,         ...... 

Spt.  chloroform.,         ..... 

I'ulv.  acacise,      ...... 

Aquam  ad  .         .         . 

A  teaspoonful  every  four  hours. 
Formula  33 : 

R.  Acid,  nitric,  dil., 
Tinct.  camph.  co., 
Spt.  chloroform., 
Syr.  zingib., 
Decoct,  htematoxyli  ad 

A  teaspoonful  every  four  hours. 
Formula  34 : 

Bi.  Acid,  sulph.  dil.,        . 

Spt.  chloroform.,         ........ 

Syrupi,       .......... 

Aquam  ad  ......... 

A  teaspoonful  every  four  hours. 
Formula  35  : 

R.  Acid,  nitric,  dil., ,         .         . 

Syr.  gummi  rubr.,       ........ 

Spt.  chloroform.,         ........ 

Decoct,  hsematoxyli  ad       ......         . 

A  teaspoonful  every  four  hours. 
These  prescriptions  are  suitable  for  children  of  a  yea.r  old. 

Formula  36 : 

R.  Ext.  belse  liquid, 

Syr.  gummi  rubr.,       ........ 

Tinct.  camph.  co.,       ........ 

Syr.  zingib.,        ......... 

Aquam  ad  ......... 

A  teaspoonful  three  or  four  times  a  day.     For  children  six  years 
Formula  37  : 

R.  Cupri  sulph.,     ......... 

Liq.  opii  sed.,    . 

Spt.  chloroform.,        ........ 

Aquam  cinnamomi  ad        ......         . 

Two  teaspoonfuls  three  times  a  day.     For  cliildren  six  years  of 


3J 

5iss. — M. 


3'i 

wjjxx 

3ss. 
Siss.— M. 


"Kxxiv 

5i 

"Kxij 
giss.— M. 


3ss. 

giss.— M. 


w)Jxx 

nijxx 

giss.— M. 


31J 

Jiss. — M. 
of  age. 


'i^xxiv 
5iij.-M. 


DIAERHCEA.  193 

not  answered  my  expectations,  and  I  have  been  so  frequently  dis- 
appointed with  it  that  I  now  seldom  employ  it.  The  syrup  of  red 
gum,  combined  with  nitric  acid  and  logwood  (Form.  35),  or  with 
the  extract  of  bael,  are  all  useful  (Form.  36).  A  dose  of  castor- 
oil  paste  (Form.  23)  may  be  needed  to  remove  irritant  matter  from 
the  bowels,  and  especially  in  those  cases  where  exposure  to  cold 
has  chilled  the  surface  and  increased  the  cono-estion  of  the  internal 
organs. 

Sulphate  of  copper  is  another  remedy  to  be  employed  with 
opium,  and  a  few  drops  of  spirit  of  chloroform  in  special  cases 
(Form.  37). 

In  very  obstinate  cases  enemata  of  starch  and  opium  may  be 
necessary.  I  found  no  remedies  administered  by  the  mouth  check 
the  alvine  discharges  so  effectuallv  as  one  used  nio-ht  and  mornino- 
in  a  case  depending  on  mesenteric  disease.  In  very  obstinate  cases 
Trousseau  employs  an  enema  of  one  grain  of  nitrate  of  silver  dis- 
solved in  an  ounce  of  w^ater.  In  the  dysenteric  diarrhoea  of  chil- 
dren, Dr.  Ringer  speaks  favorably  of  salicylic  acid  used  as  an  in- 
jection (1  to  300).* 

This  chronic  diarrhoea  indicates  a  relaxed  state  of  the  system 
generally  and  loss  of  tone,  A  tonic  regime  is  consequently  re- 
quired, and  frequently  gives  relief  when  other  remedies  have  failed. 
Thus,  change  of  air,  by  altering  the  surrounding  circumstances,  is 
often  of  incalculable  benefit.  Removal  to  the  seaside,  or  some 
dry  and  healthy  locality,  will  accomplish  more  than  any  drugs 
when  the  case  has  assumed  a  chronic  character  and  the  bowels  are 
irregular  in  their  action.  Cold  baths  in  the  morning,  or  if  the 
little  patient  be  very  feeble,  baths  with  the  chill  taken  off,  with 
friction  and  shampooing,  tend  to  brace  up  the  relaxed  tissues. 
Benefit  is  frequently  obtained  from  the  use  of  cod-liver  oil,  steel 
wine,  malt  extract,  and  other  remedies  of  a  similar  invigorating 
character.  Every  case  of  diarrhoea  demands  care,  from  its  liability 
under  neglect  to  lead  to  the  severe  forms  we  have  described,  or  to 
originate  mischief  in  the  brain,  or  tubercle,  or  marasmus,  as  the 
general  strength  becomes  more  and  more  reduced. 

Prolajjsus  Ani.' — In  cases  of  long-continued  diarrhoea  the  sphinc- 
ter ani  loses  its  contractility,  and  the  surrounding  parts  become 
relaxed.     When  the  diarrhoea  is  cured  the  local  irritation  ceases, 

*  Handbook  of  Therapeutics,  8th  edition,  p.  599. 
13 


194  DISEASES   OF   CHILDREN. 

and  the  child's  bowels  may  act  once  or  twice  daily  without  any 
protrusion  of  the  rectum.  The  treatment  consists  in  sponging 
the  relaxed  parts  with  cold  water,  and  if  there  is  tenesmus  an 
opiate  enema  after  the  bowels  act  will  be  of  service.  Another 
plan  is  to  wash  away  all  fecal  matter  from  the  gut,  and  then 
apply  a  strong  solution  of  alum  before  it  is  returned.  When  the 
gut  remains  protruded, apart  from  any  action  of  the  bowels,  gentle 
pressure  with  the  finger  dipped  in  oil  will  cause  it  to  return.  Cold 
water  enemata  every  morning  are  serviceable  in  this  state  of  re- 
laxation. I  have  found  great  benefit  from  the  use  of  sulphate  of 
iron  and  infusion  of  quassia  as  a  valuable  astringent  enema,*  and 
the  decoction  of  tormentilla  has  also  been  recommended.  Where 
the  prolapsus  ani  is  not  the  result  of  diarrhoea,  but  is  rather  a 
chronic  condition,  it  is  well  to  hold  the  child  in  the  hands  whilst 
the  bowels  are  being  relieved,  as,  by  so  doing,  the  gut  will  rarely 
be  forced  down.  If,  on  the  other  hand,  the  child  is  placed  where 
its  feet  can  reach  the  ground,  it  will  make  such  powerful  expul- 
sive efforts  as  will  commonly  cause  protrusion.  Another  plan  is 
to  keep  the  little  patient  lying  on  its  back  whilst  the  motions  are 
passed.  A  compress  and  bandage  may  be  worn  during  the  day 
to  prevent  descent. 


CHAPTER    XYI. 

GASTRITIS — MEL^NA — DYSENTERY. 

Gastritis  :  Symptoms — Causes  and  treatment.  Softening  of  the  Stomach  :  Nature 
and  causes.  H^ematemesis  and  Mel^na  :  Causes^Symptoms  and  treatment. 
Dysentery  :  Symptoms — Causes — Pathology  and  treatment. 

Gastritis  is  of  rare  occurrence  in  children,  and  the  symptoms 
are  too  obscure  to  enable  us  to  diagnose  the  disease  with  any 
approach  to  certainty.  Catarrh  of  the  gastric  mucous  membrane 
{gastritis  mucosa)  has  been  referred  to  active  hypercemia ;  it  occurs 
in  the  case  of  drunkards,  as  well  as  in  chronic  heart  disease  and 
pulmonary  phthisis.     The  anatomical  changes  in  this  state  are  a 

*  Formula  38 : 

R.  Ferri  sulphat., 3J 

Inf.  quassise, o^iij' — M. 

Fiat  enema.     A  fourth  part  to  be  used  every  morning. 


GASTRITIS.  1 95 

dark-reddish  slate-gray  discoloration  of  the  mucous  membrane, 
spots  of  ecchymosis,  and  a  general  hypertrophy  of  the  parietes  of 
the  stomach.*  The  disease  niay  be  induced  by  irritating  articles 
of  food,  and  by  swallowing  corrosive  acrid  substances,  or  from  any 
causes  which  excite  indigestion  or  flatulence.  The  stomach  may 
exhibit  the  evidence  of  gastric  catarrh  after  death  in  those  chil- 
dren who,  during  life,  have  had  no  symptoms  of  the  disease,  nor 
even  disturbance  of  digestion. 

The  symptoms  are  distension  and  pain  at  the  epigastrium, 
increased  on  pressure,  vomiting  of  a  glairy  mucus  or  greenish 
secretion,  and  constant  retching  after  food.  If  the  disease  goes 
on  the  child  becomes  thin  and  emaciated  ;  there  is  thirst,  and  the 
tongue  is  covered  with  a  thick  white  fur ;  the  pulse  is  frequent 
and  small  in  acute  cases,  and  there  is  constipation  alternating  with 
diarrhoea  ;  but  a  subacute  form  of  gastritis  may  be  present,  giving 
rise  to  no  more  symptoms  than  are  ordinarily  to  be  met  with  in 
irritative  dyspepsia.  If  this  continues  the  nutrition  of  the  child 
sutFers,  and  it  loses  flesh  and  strength. 

The  treatment  consists  in  giving  cold  water  and  sedatives  after 
a  careful  regulation  of  the  diet.  Whilst  pain  and  sickness  con- 
tinue, milk  in  small  quantities  at  a  time  is  the  best  form  of  nour- 
ishment, and  it  may  be  necessary  to  add  a  little  lime-water  to 
assist  digestion.  For  the  relief  of  the  profuse  gastric  secretion, 
Vogelf  recommends  half  a  grain  of  nitrate  of  silver  in  three  ounces 
of  water  as  a  mixture,  of  which  two  teaspoonfuls  may  be  given  to 
children  from  one  to  two  years  of  age.  For  older  children  he  gives 
a  sixth  of  a  grain  of  nitrate  of  silver. 

But  gastritis,  of  a  subacute  character,  demands  that  bland  and 
non-irritating  food  should  be  taken,  cold  or  iced  water  to  allay 
thirst,  and  bicarbonate  of  potash  and  hydrocyanic  acid  as  a  seda- 
tive to  the  mucous  membrane.  If  there  is  much  irritability  of  the 
stomach,  a  grain  of  calomel,  with  a  few  grains  of  tragacanth 
powder,  divided  into  six  parts,  and  given  in  the  space  of  twenty- 
four  hours,  will  be  a  serviceable  remedy.  Poultices  may  be  ap- 
plied to  the  epigastrium  if  the  pain  does  not  yield  to  the  remedies 
mentioned,  and  enemata  are  preferable  to  purgatives. 

In  cases  of  gastritis  produced  traumatically  the  best  treatment 
probably  is  that  of  opium  and  bismuth. 

*  Rokitansky,  Path.  Anat.,  vol.  ii,  p.  257. 
t  Diseases  of  Children,  1874,  p.  141. 


196  DISEASES    OF    CHILDREN. 

Softening  of  the  Stomach. — It  is  most  important  not  to  mistake 
the  appearance  found  in  the  stomach  after  death,  from  the  action 
of  the  gastric  juice,  with  those  that  result  from  disease,  or  the 
introduction  of  irritating  substances.  The  experiments  of  Hunter 
showed  that  the  gastric  juice  after  death  was  capable  of  discolor- 
ing the  coats  of  the  stomach,  more  especially  in  those  persons  who 
had  died  suddenly.  As  many  individuals  were  quite  well  up  to 
the  time  of  death,  he  believed  that  these  changes  were  caused  by 
the  action  of  the  gastric  juice  after  life  was  extinct. 

In  some  instances,  the  process  is  limited  to  the  mucous  mem- 
brane, which  is  softer  than  usual,  and  breaks  down  under  slight 
pressure  of  the  finger ;  in  other  instances,  the  morbid  change  is 
greater,  and  it  extends  through  all  the  coats,  by  means  of  a  soft 
irregular  ulcer,  the  contents  of  the  stomach  escaping  into  the  peri- 
toneal cavity.  The  diseased  process  most  frequently  attacks  the 
fundus  of  the  organ,  where  the  fluids  gravitate,  and  the  bloodves- 
sels ramifj'ing  over  the  coats  of  the  stomach  are  dark  and  con- 
gested, producing  a  condition  resembling  chronic  inflammation. 
Adherent  to  the  interior  membrane  may  be  seen  an  opaque  or 
brownish  tenacious  mucus,  which  is  easily  removed  on  pouring 
over  it  a  slight  stream  of  water. 

The  disease  appears  to  be  not  uncommon  in  infancy  and  early 
life,  when  gastric  disorder  is  so  frequent,  but  I  am  not  able  to  refer 
to  any  symptoms,  either  in  my  own  experience,  or  that  of  others, 
which  would  enable  us  to  say  during  life,  that  softening  of  the 
stomach  would  be  found  after  death. 

Softening  of  the  intestines  has  also  been  mentioned  by  writers  on 
medicine,  the  mucous  membrane  becoming  softened  or  destroyed 
down  to  the  peritoneal  investment. 

HcEinatemesis  and  Meloena  Vera. — Infants  of  a  few  days  old 
Bufter  occasionally  from  vomiting  or  purging  of  blood,  sometimes 
from  both.  "  It  is  essentially  a  disease  of  the  early  days  of  life, 
generally  occuring  between  the  first  and  sixth  day."*  Dr.  Rahn 
Escher  considers  that  the  hasmorrhage  is  greatest  within  the  first 
t went}' -four  hours  of  life,  usually  ceases  on  the  second  day,  but 
may  continue  to  the  fifth,  or  even  later. 

■Causes. — In  man}'  cases  it  is  impossible  to  find  out  the  source  of 
the  hferaorrhage.  Various  opinions  have  been  oftered  as  to  the 
cause  of  this  rare  and  obscure  condition.     The  disease  would  ap- 

*  Diseases  of  Infancy  and  Childhood,  by  T.  H.  Tanner,  M.D.,  p.  116. 


SOFTENING   OF   THE   STOMACH.  197 

pear  to  depend  cljiei3y  on  the  physiological  changes  which  take 
place  at  birth,  when  respiration  becomes  established,  and  the  lungs, 
liver,  spleen,  and  intestines  are  liable  to  become  congested  through 
an  increase  of  pressure  on  the  venous  system  ;  hence  one  reason, 
probably,  why  convulsions  are  frequent  after  birth  in  delicate  chil- 
dren. Tedious  labor  and  the  pressure  of  instruments  are  mentioned 
as  factors  in  the  production  of  the  hfemorrhage.  Some  cases  are 
on  record  which  show  a  hereditary  tendency  to  bleed  in  the 
parents.* 

Of  twenty-two  cases  recorded  by  Rilliet  and  Barthez,  twelve 
recovered.  These  were  probably  cases  of  pressure  of  the  child's 
head  during  tedious  labor,  and  congestion  of  the  venous  system 
from  a  difficulty  in  establishing  respiration  at  birth. f  "  Taking 
the  cases  altogether,  the  mortality  is  about  60  per  cent."  (Groom.) 

Pathology. — Some  authorities  consider  the  haemorrhage  as  a 
crisis  of  the  plethoric  condition,  and  such  cases  would  appear  to  be 
by  no  means  uncommon  in  the  newly  born,  there  being  general 
cong-estion  of  the  inteo-uments  and  chief  internal  organs.  Cases 
are  recorded  which  show  that  it  is  sometimes  due  to  blood  cha^nge, 
as  in  purpura  h?emorrhagica.  Bouchut  quotes  from  Billard  (p. 
497)  the  case  of  an  infant,  five  days  old,  whose  trunk,  limbs,  and 
arms  were  covered  with  violet  petechise,  and  the  yellowish  spaces 
between  them  (from  the  slight  jaundice  which  was  present)  gave 
the  surface  "  a  tiger-like  aspect."  After  death,  dark  blood  was 
found  in  the  intestines  and  stomach,  the  spleen  had  ruptured  from 
over-engorgement,  and  the  heart  was  full  of  blood ;  the  cellular 
tissues  contained  large  ecchymoses,  as  did  the  kidneys  and  bladder ; 
the  pleurae  presented  petechite,  and  the  brain  was  congested. 

After  death,  in  ordinary  cases,  the  internal  organs  have  been 
found  exsanguine,  but  healthy.  Spiegelberg  and  Landau  report 
cases  in  which  abscesses  were  found  in  the  duodenum,  arising  from, 
embolism.     Cases  of  this  kind  never  recover.:]: 

The  symjptoms  are  prostration  of  the  strength,  pallor,  rapidl 
breathing,  inability  to  suck,  small  pulse,  and  occasionally  convul- 
sions. Cases  W'hich  survive  the  shock  may  end  in  diarrhoea, 
hydrocephalus,  or  mesenteric  disease. 

*  Melfena  Neonatorum,  by  J.  Halliday  Crooni,  M.B.,  Med.  Times  and  Gazette,  Oct. 
23d,  1880,  p.  480. 

f  Traite  Clinique  et  Pratiqxie  des  Maladies  des  Enfans,  Paris,  vol.  ii,  18-53. 

:j:  Melfena  Neonatorum,  by  J.  Halliday  Groom,  M.B.,  Med.  Times  and  Gazette,  Oct.. 
23d,  1880,  p.  480. 


198  DISEASES   OF   CHILDREN. 

Blood  drawn  from  the  nipple  in  suckling  {spurious  hcBmatemesis) 
must  not  be  mistaken  for  true  hsematemesis. 

Treatment. — This  is  unsatisfactory  and  uncertain  ;  little,  if  any- 
thing, can  be  done.  Astringent  enemata  with  cold  water  where 
the  haemorrhage  from  the  bowels  is  bright  and  active,  or  even 
cold  applications  to  the  abdomen,  may  be  suitable  in  some  cases. 
When  faintness  and  exhaustion  threaten,  ammonia,  ether,  etc., 
will  be  required. 

Dysentery. — Young  children  are  sometimes  seized  with  this 
disorder,  but  it  is  very  rare,  and  it  is  not  improbable  that  intestinal 
haemorrhage  has  been  mistaken  for  it.  When  the  stools  are  slimy 
and  contain  mucus,  there  is  afi  alteration  in  the  intestinal  mucous 
membrane,  and,  if  it  lasts,  more  or  less  blood  may  be  mixed  with 
them.  In  some  chronic  cases  the  evacuations  are  little  more  than 
lumps  of  blood  and  mucus,  dark  in  some  instances,  and  pink  or 
bright  red  in  others.  In  aggravated  cases,  the  bowel  discharges 
are  so  altered  that  they  become  oifensive,  and  of  a  slate-gray 
hue  from  containing  portions  of  mucous  membrane  which  have 
sloughed,  and  there  is  a  discharge  of  pus,  indicating  the  presence 
of  ulceration.  Dysentery  may  begin  as  a  primary  disease,  or 
commence  as  simple  diarrhoea,  and  depend  upon  the  same  causes  ; 
the  inflammatory  form  of  diarrhoea  [eniero-colitis]  is  closely  con- 
nected with  it. 

The  symptoms  resemble  those  of  entero-colitis,  but  are  more 
severe ;  they  usually  begin  with  violent  sickness  and  vomiting, 
when  the  disease  is  acute,  accompanied  with  shivering  and  pallor. 
The  motions  at  the  onset  may  be  copious,  and  for  the  first  few 
days  of  a  bilious  character,  then  they  become  more  scanty  and 
slimy,  with  glairy  mucus  resembling  white  of  egg,  and  mixed 
with  blood.  Sometimes  pure  blood  escapes,  but  generally  it  is 
mixed  with  the  fecal  matter,  which  now  and  then  escapes  in 
lumps,  causing  griping  pain  in  the  abdomen,  tenesmus,  cramps  in 
the  thighs,  and  difficulty  in  micturition.  There  are  abdominal 
pain  and  tenderness  in  the  course  of  the  colon,  and  frequently 
around  the  navel.  Fever  is  seldom  present  unless  the  disease 
lasts  some  time,  when  the  skin  becomes  harsh  and  hot,  and  the 
pulse  frequent. 

When  the  disease  assumes  a  chronic  form,  the  child  becomes 
emaciated,  and  the  bowel  discharges  are  mixed  with  pus  and 
■blood  ;  there  are  pieces  of  lymph  in  the  motions,  which  are  very 


dysejSitery.  199 

acrid  and  offensive.  The  cliild  is  restless,  and  cannot  sleep  at 
night  from  pain  and  tenderness  ;  there  is  gradual  loss  of  flesh, 
prostration  of  strength,  constant  thirst,  nausea,  and  disinclination 
for  food.  "  Of  thirty-six  cases,  the  termination  of  which  we  have 
recorded,  four  proved  fatal."  (Meigs  and  Pepper.)  The  com- 
plaint may  terminate  in  peritonitis  and  ascites,  in  mesenteric 
disease  and  hectic  fever,  or  in  a  sudden  fit  of  convulsions.  When 
the  disease  is  progressing  towards  recovery,  the  evacuations 
become  less  frequent,  and  blood  no  longer  appears  in  them ;  the 
child  ceases  to  be  feverish,  and  rests  at  night,  whilst  the  appetite 
returns. 

Causes. — The  disease  is  more  frequent  in  hot  summer  weather, 
when  unripe  fruit  is  eaten,  and  bowel  disorders  are  common. 
Improper  feeding,  defective  ventilation,  scanty  clothing,  impure 
water,  and  exposure  to  cold  and  damp,  are  all  capable  of  origin- 
ating the  disease.  The  influence  of  malaria,  too,  is  to  be  reckoned 
as  a  cause,  as  well  as  the  exanthemata,  particularly  measles  and 
variola  (Meigs  and  Pepper),  and  diseased  intestine  from  typhoid. 

Pathology. — -In  the  acute  stage  of  the  disorder,  the  morbid 
changes  are  to  be  seen  in  the  large  intestine  and  rectum,  as  in 
entero-colitis.  It  resembles  this  disease,  except  that  the  changes 
in  the  rectum  and  colon  are  greater,  and  it  often  exists  in  an 
endemic  and  epidermic  form.  In  some  cases  the  small  intestines 
are  involved ;  the  mucous  membrane  is  swollen,  soft,  and  reddened 
in  patches  or  throughout  its  entire  length.  In  some  places  it 
may  assume  a  dark  or  gangrenous  appearance.  The  follicles  are 
enlarged.  In  the  more  advanced  or  chronic  stage,  small  round 
specks  of  ulceration  form,  which  finally  run  together,  and  produce 
a  ragged  uneven  appearance,  varying  in  extent  and  depth.  The 
mesenteric  glands  may  be  natural,  or  slightly  enlarged  and  red. 
In  long-standing  cases  the  ulcers  become  contracted,  and  surrounded 
by  hardened  tissue. 

Treatment. — When  the  disease  is  recent,  and  sets  in  with  acute 
symptoms,  a  warm  bath  is  of  great  service,  followed  by  poultices 
to  the  abdomen.  The  most  absolute  rest  and  warmth  are  de- 
manded, and,  if  there  is  no  vomiting,  the  castor-oil  paste  (Form. 
23),  with  a  drop  or  two  of  laudanum,  will  be  necessary  to  adminis- 
ter in  order  to  clear  the  bowels  of  any  scybalee  (Form.  24).  If 
there  be  tenesmus  and  straining,  an  opiate  clyster  will  give  great 
relief.     In  some  form  or  other  opium  is  the  most  valuable  remedy 


200  DISEASES   OF   CHIL.DEEN. 

we  possess  in  this  complaint,  as  it  controls  the  action  of  the  bowels, 
allays  pain,  and  procures  sleep.  Acetate  of  lead,  catechu,  kra- 
meria,  sulphate  of  copper  (Form.  29,  31,  32,  37),  will  at  once  come 
to  our  aid  in  turn^  when  the  bowels  continue  obstinately  irritable. 

When  calomel  is  employed,  it  should  be  given  in  very  small 
doses  at  an  early  stage,  in  combination  with  opium  or  Dover's 
powder,  but  its  use  requires  extreme  caution. 

jS^itrate  of  silver  has  been  recommended,  in  combination  with  a 
few  drops  of  opium,  given  in  some  suitable  vehicle,  like  mucilage 
or  syrup.  The  eighth  of  a  grain  may  be  given  to  a  child  two 
years  old  every  three  or  four  hours. 

As  regards  diet,  if  an  infant,  it  should  be  kept  to  the  breast, 
and  no  other  form  of  food  given.  Older  children  may  have  barley- 
water,  sago,  tapioca,  rice-water,  etc.,  as  mentioned  under  the  treat- 
ment of  chronic  diarrhcea. 


CHAPTER    XYIL 

CONSTIPATION    AND    COLIC. 

Causes  op  CoxsTlPATioif :  General  dehility — Diet — Deficiency  of  gastric,  hepatic  and 
intestinal  secretions — Torpor  of  intestines  from  atony  nf  their  muscular  fibres — A  fre- 
quent accompaniment  of  cerebral  disease — Hernia  and  intussusception.  Treatmext  : 
Regulation  of  diet — Laxatives — Aperients — I^itrohydrochlorie  acid  and  taraxacum — 
Belladonna — Strychnia — Enemata.  Causes  of  Colic  :  Diet — Poisonous  or  irritat- 
ing substances — Flatulence — Presence  ofseybalm  in  intestines.  SYMPTOirs  AND  Diag- 
nosis FROM  Peritonitis:  Treatment:  Castor  oil  and  opium — Use  of  enemoia — 
Hot  poultices — Belladonna — Hydrate  of  chloral  and  bromide  of  potassium. 

Constipation  is  one  of  the  commonest  disorders  of  early  life. 
When  it  occurs  in  infants  it  is  a  source  of  much  trouble  to  the 
mother,  who  is  sorely  tried  with  the  difficulty,  because  the  child 
cannot  thrive  without  a  frequent  action  of  the  bowels.  The 
younger  a  child  is  the  oftener  should  the  bowels  act.  In  inftxnts 
they  are  moved  throe  or  four  times  a  day  ;  and  in  children  over 
one  year  there  are  generally  two  evacuations  daily. 

Among  children  artificially  reared,  constipation  is  a  frequent 
ailment,  particularly  if  they  are  feeble.  There  is  deficiency  of  in- 
testinal secretion,  so  th^t  by  the  time  the  motions  reach  the  large 
intestine  and  rectum  they  are  extremely  hard  and  pebbly,  and  the 


CONSTIPATION   AND    COLIC.  201 

child  cries  and  undergoes  painful  straining  to  evacuate  the  hard- 
ened masses.  Eest  is  not  obtainable  at  night  from  flatulence, 
the  belly  becomes  swollen,  the  legs  are  spasmodically  drawn  up, 
and  then  stretched  out  again.  If  this  state  of  things  is  suffered 
to  go  on,  the  child  may  have  a  convulsion,  or  die  worn  out  with 
pain  and  exhaustion.  An  accumulation  of  gas  in  the  intestines 
may  occur  in  these  cases,  especially  where  the  secretion  of  bile  is 
scanty,  and  those  articles  of  diet  are  indulged  in  which  cause  fer- 
mentation. When  the  amount  of  mucus  is  sparingly  secreted,  the 
muscular  fibre  fails  to  propel  the  contents  of  the  bowel,  and  hence 
constipation  is  common  in  such  cases. 

The  color  of  the  faeces  depends  upon  the  admixture  of  bile,  and 
the  motions  may  be  brown,  green,  or  almost  black,  or  like  clay. 
When  bile  is  deficient,  the  motions  are  pale  ;  ordinarily  they  are 
of  a  gingerbread  hue.  "  The  consistency  of  the  f^ces  also  varies 
considerably  ;  they  are  liquid  w-hen  the  serous  exhalation  of  the 
mucous  membrane  is  excessive  ;  semifluid  when  the  secretion  is 
muco-gelatinous,  or  they  are  mixed  with  the  secretion  of  the 
shape  of  grumous  particles.  The  feculent  matter  found  above 
the  various  intestinal  strictures  presents  a  ];>eculiar  frothy  appear- 
ance."* Constipation,  too,  in  older  children  is  sometimes  caused 
by  starch  compounds,  as  rice,  arrowroot,  tea,  astringent  and  tonic 
mixtures.  And,  according  to  my  experience,  it  often  originates 
in  the  neglect  of  parents  to  inculcate  the  habit  of  getting  the 
bowels  to  act  at  stated  hours.  Constipation  is  also  a  frequent 
accompaniment  of  cerebral  disease,  as  meningitis,  hydrocephalus? 
marasmus,  in  consequence  of  a  loss  of  tone  in  the  muscular  fibre 
of  the  intestinal  coats. 

Constipation  is  likewise  observable  in  children  with  sluggish 
livers,  who  are  not  otherwise  ill.  The  complexion  is  sallow  and 
the  appetite  capricious,  the  motions  are  pale  and  contain  scarcely 
a  trace  of  bile.  The  tongue  is  coated,  the  urine  scanty  and  high- 
colored,  and  headaclie  and  lassitude  are  also  common.  These 
symjDtoms  often  arise  from  overfeeding  and  eating  greedily. 

I  have  elsewhere  alluded  to  constipation  as  the  consequence  of 
hernia,  intussusception,  and  intestinal  obstruction. f  Imperforate 
anus  is  another  cause. 

The  symptoms  generally  met  with  in  constipation  are  distension 

*  Eokitansky,  Path.  Anatomy,  vol.  ii,  p.  110,  Syd.  Soc,  1849. 
t  See  Chap.  XVIII-XIX. 


202  DISEASES   OF   CHILDEEX. 

of  the  abdomen  from  tympanites  ;  the  bowels  having  lost  their 
contractile  power,  expand  and  push  up  the  liver,  stomach,  and 
spleen,  thus  interfering  w^ith  the  descent  of  the  diaphragm.  In 
these  cases  the  abdomen  after  a  time  becomes  painfal,  and  the 
child  is  restless,  the  tongue  is  furred,  the  mouth  hot,  and  there 
is  sometimes  vomiting. 

In  many  simple  and  uncomplicated  cases,  the  symptoms  are  not 
so  marked,  the  abdomen  is  more  or  less  tense,  and  there  are  scanty 
dry  evacuations,  heaviness  of  manner,  loss  of  appetite  and  thirst. 
Habitual  constipation  may  cause  convulsions  in  young  children. 

Whilst  constipation  is  most  common  in  delicate  children,  espe- 
cially if  brought  up  by  hand,  it  is  of  frequent  occurrence  in  strong 
children  who  are  so  reared ;  and  heiice  I  am  inclined  to  credit 
injudicious  feeding  as  a  cause.  I  have  over  and  over  again  seen 
the  strongest  and  best-developed  children  so  attacked ;  they 
are  plump,  bright,  and  healthy-looking,  tbe  only  ailment  being  a 
painful  straining  in  emptying  the  bowels.  Now,  in  these  cases, 
although  the  skin  is  of  a  normal  hue,  and  the  conjunctivae  of 
pearly  brightness,  deficient  biliary  secretion  is  the  essential  cause  of 
the  evil ;  and  until  the  liver  pours  out  more  bile,  there  is  no  proba- 
bility of  relief.  When  the  liver  has  been  stirred  up  by  a  mer- 
curial purgative,  the  bowels  have  become  regulated,  and  a 
recurrence  of  the  evil  has  only  happened  with  food,  improper  in 
quantity  or  quality. 

Treatment. — No  remedies  will  be  of  any  use  till  we  have  ascer- 
tained the  cause  ;  and  the  first  step  to  take  under  any  circum- 
stances will  be  a  proper  regulation  of  the  diet.  To  prescribe 
drugs  till  this  is  inquired  into  will  be  a  fruitless  proceeding.  Milk 
ought  to  enter  largely  into  the  dietary  of  young  children,  and 
weak  animal  broths  in  place  of  mucilaginous  and  starchy  foods, 
with  a  liberal  allowance  of  cold  water.  If  the  child  is  old  enough, 
Scotch  oatmeal  with  milk  once  a  day  is  an  excellent  remedy  to 
keep  the  bowels  open.  The  oatmeal  and  treacle  biscuits  made  by 
Scotch  confectioners  and  bakers,  or  the  so-called  "Yorkshire 
parkin,"  is  a  famous  aperient  food  for  children.  These  biscuits 
may  be  procured  of  Macalpiue  &  Co.,  287  Oxford  Street.  Prunes 
and  senna  are  also  serviceable,  and  if  in  season,  a  few  grapes  or  a 
baked  apple  maj'' be  allowed.  In  infants  and  children  of  a  few 
months  old,  the  castor-oil  paste  is  a  safe  aperient  (Form.  23),  re- 
lieving the  flatulence  and  exciting  the  action  of  the  bowels.     The 


CONSTIPATION   AND    COLIC.  203 

syrup  of  rhubarb  is  another  good  remecl.y,  and  manna  is  a  safe  and 
mild  laxative  which  infants  take  readily.*  Manna  may  also  be 
given  in  the  form  of  paste  with  a  little  cream  of  tartar.f  A  sup- 
positorj^  of  common  yellow  soap  introduced  into  the  rectum  at 
night  will  sometimes  cause  the  bowels  to  act  naturally  in  the  early 
morning.  A  child  delicate  from  birth  suffered  from  constipation, 
passing  motions  resembling  clay  marbles  in  color  and  shape ;  it 
was  never  easy  day  or  night.  All  treatment  failed  to  give  relief 
till  at  six  months  old,  malt  extract,  mixed  with  milk,  was  tried, 
and  in  a  very  short  time  the  motions  became  natural  and  the 
bowels  regular. 

In  older  children  I.  have  known  treacle  and  bread  insure  a 
daily  and  regular  action  of  the  bowels. :{;  In  some  strong  children 
where  febrile  disturbance  and  heat  of  surface  attend  constipation, 
a  few  grains  of  sulphate  of  magnesia  with  cinnamon,  which  dis- 
guises the  taste,  will  answer  extremely  weJl,§  or  (Form.  8),  regu- 
latino;  the  dose  accordino;  to  the  age  of  the  child.  If  the  com- 
plexion  is  sallow,  the  urine  turbid,  or  if  the  motions  indicate  a 
deficiency  of  bile,  a  little  gray  powder  w^ith  rhubarb  and  bicarbo- 
nate of  soda  may  be  given  with  advantage  for  a  few  nights,  and 
a  citrate  of  potash  mixture  during  the  day.  In  some  cases,  if  the 
belly  is  tumid  and  the  hepatic  secretion  habitually  defective,  small 
doses  of  the  perchloride  of  mercury  may  be  ordered  with  tincture 
of  cinchona  and  taraxacum.  I  have  also  seen  excellent  effects 
follow  the  administration  of  nitrohydrochloric  acid  with  taraxa- 

*  Formula  39 : 

R.  Mannpe  opt., gij 

Aquse  anethi,    .........     5J. — M. 

A  teaspoonful  once  in  two  or  three  hours  till  the  bowels  act.     For  children  from  four 
to  six  months  old. 
f  Formula  40 : 

R.  Potass,  bitart., gss. 

Mannse, o^"- 

Aquam  anethi  ad      ........     ^iss. — M. 

About  gr.  X  or  gr.  xv  for  a  dose,  to  be  .repeated  occasionally.     For  children  from 
four  to  six  months  old. 
X  See  Chapter  II. 
§  Formula  41 : 

R.  Magnes.  sulph.,         . 3j 

Syr.  rhei, ^ss. 

Tinct.  cinnam.  co., 3ss. 

Liq.  magnes.  carb.  ad       .         .         .         .         .         .         .     3iss. — M. 

One  or  two  teaspoonfuls  occasionally.     For  children  from  four  to  six  months  old. 


204  DISEASES    OF    CHLLDEEX. 

cum*  where  the  liver  is  sluggish,  and  the  child  is  torpid  and  pale, 
and  needs  a  tonic  and  alterative  at  the  same  time.  The  Pulv. 
Gljcjrrhizge  Co.  (Ger.),  which  contains  sulphur  is  an  admirable 
aperient  for  children,  and  is  not  disagreeable  to  take. 

Lastlv,  there  are  cases  repeatedly  met  with  where  it  should  be 
our  object  to  give  as  little  aperient  medicine  as  possible  by  the 
mouth,  because  the  constipation  depends  on  a  laxity  of  the  intes- 
tinal fibre.  A  judicious  combination  of  belladonna  and  strychnia 
is  to  be  recommended  in  obstinate  constipation,  but  if  in  spite  of 
these  remedies  and  diet,  the  bowels  remain  persistently  costive,  a 
two-ounce  enema  of  warm  soap  and  water  will  rouse  them  to 
activitv,  and  render  soluble  the  fecal  masses  which  are  lodged  in 
the  descending  bowel  and  rectum.  This  may  be  used  for  infants 
and  children  of  any  age. 

In  every  case  of  obstinate  constipation,  the  finger  well  oiled,  or 
an  elastic  tube  should  be  passed  up  the  bowel  to  ascertain  if  any 
hernia  or  mechanical  obstruction  exists  for  if  it  does,  all  treatment 
by  the  mouth  will  be  unavailing  until  it  is  removed. 

Experience,  however,  teaches  us  the  danger  of  too  active  inter- 
ference in  cases  of  constipation,  unless  urgent  symptoms  are 
present ;  the  bowels  may  be  torpid  for  days  or  weeks  together  in 
exceptional  cases,  without  danger  to  life.f 

*  Formula  42 : 

R.  Acid,  nitric  dil., "Xxvj 

Acid,  hvdrochl.  dil., 


Succi  taraxaci, 
Svrupi, 
Aquam  ad 


3ss. 

3SS. 
.^iv.— M. 


A  dessertspoonful  three  times  a  day.     For  a  child  three  or  four  years  old. 

t  Mr.  .John  Gay  has  recorded  a  case  of  obstinate  constipation  in  a  boy  aged  seven, 
of  healthy  appearance,  who  was  admitted  into  the  Koyal  Free  Hospital,  in  July,  1853. 
Four  years  previously  he  had  an  attack  of  typhus  fever,  accompanied  with  pain  and 
tenderness.  On  recovery  his  bowels  were  torpid,  and  purgatives  and  enemata  were 
needed  to  procure  evacuations  from  them.  '•'  Daring  the  three  months  prior  to  his 
admission,  nothing  whatever  pa.*sed  from  his  bowels."  Neither  his  health  nor  appetite 
suffered,  and  he  had  only  been  sick  on  one  or  two  occasions  in  consequence  of  taking 
unwholesome  food.  The  umbilical  measurement  increased  to  forty-nine  inches  without 
material  inconvenience  to  the  respiratory  organs.  Along  the  left  side  of  the  body  was 
a  prominent  swelling,  corresponding  to  an  enlarged  descending  colon.  One  remedy  after 
another  failed  to  dislodge  any  fecal  matter,  and  at  la.st  a  speculum  was  introduced  into 
the  rectum,  and  the  sphincter  dilated  ;  then  the  tube  of  an  enema  syringe  was  passed 
high  up  into  the  bowel,  and  a  stream  of  warm  water  kept  constantly  playing  for  half 
an  hour  upon  the  contents  till  they  were  dissolved.    These  repeated  operations  brought 


CONSTIPATION   AND   COLIC.  206 

Colic  is  a  common  complaint  in  young  children.  It  consists  in 
painful  contraction  of  the  intestinal  coats,  and  is  caused  by  the 
accumulation  of  hard  fecal  matter  in  the  bowels,  or  some  irritant 
food,  or  substance  lodged  in  the  intestines.  Slight  attacks  in 
infants  are  not  uncommon  from  excessive  acidity  in  the  stomach, 
forming:  milk  into  a  hard  indigestible  curd.  In  children  it  is 
frequently  induced  by  eating  unripe  gooseberries  or  other  indi- 
gestible fruit,  and  drinking  large  quantities  of  cold  water  when 
the  stomach  is  empty  and  the  body  heated.  Worms  in  the 
bowels,  internal  strangulation,  or  obstruction  are  severally  capable 
of  causing  the  disorder.  Colic  often  accompanies  diarrhoea  in 
young  children.  Exposure  to  cold  is  another  cause,  and  so  is 
bathing  in  too  cold  water. 

The  sj/mptoms  are  sudden  twisting  pain  in  the  abdomen,  gener- 
ally in  the  direction  of  the  transverse  colon,  and  coming  on  in  par- 
oxysms. The  child  draws  up  the  legs  and  bends  the  body  forwards 
to  relax  the  abdominal  muscles.  There  is  generally  flatulence,  but 
the  suft'ering  may  be  intense,  without  any  distension  whatever,  and 
with  even  retraction  of  the  umbilicus.  When  the  gas  which  is 
naturally  formed  in  the  stomach  and  intestines  is  not  expelled  by 
the  anus,  then  the  delicate  muscular  structure  of  these  organs 
yields,  and  the  abdominal  wall  becomes  distended  and  tense.  In 
typhoid  fever  and  some  other  affections  in  v^'hich  the  ganglionic 
system  is  severely  implicated,  there  is  a  drumlike  distension  of  the 
intestines  (meteorism)  accompanied  with  quick  shallow  breathing, 
and  increased  action  of  the  heart.  The  abdomen  is  not  equally 
distended ;  it  may  be  conical  along  the  centre,  and  the  small  in- 
testines be  more  involved  than  the  colon  in  certain  cases.  I  believe 
that  in  the  latter  class,  fecal  matter  or  undigested  food  is  the  chief 
cause  of  the  pain.  In  addition  to  the  sjanptoms  just  enumerated, 
the  child  shrieks  out  with  pain,  the  angles  of  the  mouth  are  drawn 
down,  and  the  face  is  pitiable.  Syncope  and  even  convulsions 
may  happen  in  severe  cases. 

The  disease  is  to  be  distinguished  from  peritonitis  by  the  sud- 
denness of  the  pain,  and  the  freedom  from  suffering  between  the 
paroxysms;  by  the  quietude  of  the  pulse,  the.  absence  of  fever, 
and  the  relief  obtained  from  pressure.     Most  practitioners  must 

away  hard  and  fecal  matter,  like  hard  cinders,  and  soon  reduced  the  size  of  the 
abdomen  to  that  of  twenty-six  inclies  in  circumference. — Path.  Trans.,  vol.  v,  p.  174; 
also  Holmes's  System  of  Surgery,  loc.  cit. 


20G  DISEASES    OF    CHILDREN. 

have  observed  children  when  pale  with  agonj,  throw  themselves 
across  a  chair  to  obtain  the  relief  which  that  pressure  affords. 

Treatment. — If  the  case  is  one  of  simple  colic,  and  we  consider 
the  pain  to  be  due  to  muscular  contraction,  it  will  be  advisable  to 
keep  the  bowels  quiet  till  the  pain  is  relieved.  To  attain  this  end, 
flannel  wrung  out  of  warm  water  should  be  applied  to  the  abdo- 
men, or  repeated  poultices.  I  have  found  a  mixture  of  carbonate 
of  magnesia  and  spirit  of  chloroform  with  peppermint-water  very 
serviceable,  particularly  if  the  bowels  are  distended.  When  the 
pain  is  mitigated,  and  we  think  it  is  desirable  to  act  upon  the 
bowels,  a  dose  of  castor  oil  with  tincture  of  opium  and  two  or 
three  minims  of  spirit  of  chloroform  will  be  indicated.  In  infants 
at  the  breast  troubled  with  colic,  it  is  often  well  to  give  the 
mother  or  nurse  some  carbonate  of  magnesia ;  in  other  cases, 
where  the  milk  is  too  firmly  curdled  by  excessive  acidit}^  in  the 
stomach,  and  who  "possett"*  a  portion  of  this  curdled  milk, 
cajeput  oil  with  potash  is  useful. f 

A  copious  injection  of  warm  water  with  a  little  oil  will  often 
produce  speedy  relief.  When  colic  seems  to  arise  from  indigestible 
matter  in  the  stomach,  an  emetic  of  ipecacuanha  may  be  given. 

If  there  are  symptoms  of  obstruction,  they  must  be  dealt  with 
in  accordance  with  the  instructions  under  that  heading  ;|  enemata 
may  be  tried,  and  if  these  fail,  the  little  patient  must  be  kept  under 
the  influence  of  opium  and  belladonna.  The  latter  drug  is  said  to 
be  verj'  serviceable  in  the  colic  of  children. §  Hydrate  of  chloral 
and  bromide  of  potassium  are  also  useful,  by  relieving  spasm  and 
inducing  sleep. 


*  This  is  a  provincialism  for  which  we  have  ho  equivalent  in  ordinary  English  ;  it 
means  when  a  portion  of  the  milk  curdled  by  the  stomach  is  ejected  by  the  mouth. 

I  Formula  43 : 

B.    Potass,  bicarb., gr.  viij 

01.  cajeputi, "Xviij 

•    Aquae  anethi, oj- — ■^^• 

A  teaspoonful  three  times  a  day. 
X  See  Chap.  XVII. 
I  Handbook  of  Therapeutics,  by  S.  Einger,  M.D.,  4th  edit.,  p.  502. 


INTESTINAL   OBSTRUCTION.  207 

CHAPTER    XYIII. 

INTESTINAL    OBSTRUCTION. 

Causes  :  Intussusception — Fecal  accumulation  and  foreign  bodies — Hernia — Malformation 
of  rectum  and  anus — Diverticda  and  congenital  strictures — Clinical  records  of  these 
affections — Diagnosis  of  rarer  forms  of  obstruction.  Treatment  :  Reduction  of  any 
hernial  protrusion — Abdomincd  section  to  disengage  the  bowel — Enemata. 

By  obstruction  of  the  bowels  is  to  be  understood  an  interrup- 
tion to  their  functions,  arising  either  from  causes  acting  from 
without,  as  in  hernia  or  volvulus;  from  within,  as  in  fecal  accu- 
mulation; or  directly  implicating  the  walls  of  the  intestine,  as  in 
stricture. 

Intussusception  is  the  most  frequent  cause  of  acute  obstruction 
in  childhood.* 

Next  to  this,  hernia  is  not  uncommon  in  children  as  a  cause  of 
obstruction,  but  the  protruded  intestine  does  not  often  become 
strangulated  before  adolescence.  In  obscure  cases  of  obstruction, 
before  resorting  to  extreme  measures,  it  is  advisable  that  a  surgeon 
should  examine  the  abdomen  in  the  regions  where  hernia  may 
occur.  Mr.  Howard  Marsh  tabulates  forty-seven  cases  of  stranofu- 
lated  hernia  in  children,  giving  as  full  details  as  he  could  glean 
from  the  original  records  of  each  case.  This  valuable  table 
accompanies  a  paper  in  which  the  author  discusses  the  subject  at 
length. f 

In  cases  of  obstruction  in  new-born  infants  the  practitioner  may 
find  that  he  can  pass  his  little  finger  into  the  anus.  That  being 
the  case  he  must  still  bear  in  mind  that  the  rectum  may  be  im- 
perforate some  distance  above  the  anal  aperture. 

The  most  puzzling  forms  of  acute  obstruction  that  are  met  with 
in  childhood  are  those  due  to  certain  congenital  malformations  of 
the  intestinal  canal.  From  time  to  time  such  cases  come  under 
the  notice  of  the  physician. 

In  children  and  adults  no  trace  can  be  found,  as  a  rule,  of  the 
fetal  omphalo-mesenteric  duct.  But  it  sometimes  remains  as  a 
diverticulum  from  the  ileum.:}:    Close  to  this  abnormal  outgrowth 

*  See  Chap.  XIX. 

f  Eeports  Illustrating  the  Surgery  of  Childhood,  St.  Bartholomew's  Hospital  Re- 
ports, vol.  X. 

X  For  the  anatomy  of  this  condition,  see  Struthers,  On  Diverticula  from  the  Small 
Intestine,  Edin.  Med.  and  Surg.  Journal,  185^.  * 


208  DISEASES  OP  CHILDREN. 

tlie  intestine  itself  is  often  very  narrow,  not  from  any  morbid 
deposit  in  or  outside  its  coats,  nor  yet  from  ulceration  and  cicatri- 
zation, but  purely  from  ill-development. 

An  interestino;  case  is  recorded  of  "intestinal  obstruction  caused 
by  a  hernia  through  the  mesentery  of  a  Meckel's  diverticulum, 
which  had  retained  its  attachment  to  the  umbilicus."  The  patient, 
a  boy  seven  years  of  age,  was  seized  with  severe  pain  at  the  um- 
bilicus, relieved  by  the  sitting  posture.  He  had  occasionally  suf- 
fered from  attacks  of  pain.  Vomiting  set  in  on  the  third  day,  and 
continued  with  varying  severity  throughout  the  illness,  but  it  was 
never  fecal.  The  urine  was  scanty,  and  of  high  specific  gravity. 
Paroxysms  of  pain  occurred  from  time  to  time,  and  enemata 
brought  away  fecal  masses.  The  pain  abated  on  the  fifth  day, 
but  on. the  following,  increased  distension  of  the  belly  took  place, 
and  he  died.  After  death,  commencing  peritonitis  was  discovered, 
and  "  about  two  feet  of  the  lower  part  of  the  ileum  were  found 
hano-ing  in  a  collapsed  condition  on  each  side  of  a  cordlike  loop. 
This  loop  was  formed  in  the  mesentery  of  a  well-developed  diver- 
ticulum, the  upper  end  of  which  was  attached  to  the  umbilicus  by 
an  impervious  cord  half  an  inch  long,  the  diverticulum  itself  being 
four  inches  in  length.  The  gut,  where  it  passed  through  the 
loop,  ^^  as  constricted  and  pale,  but  a  small  projecting  portion  at 
the  origin  of  the  diverticulum  was  of  a  deep  purple  color."*  Two 
cases  of  fatal  obstruction,  one  in  a  girl  of  thirteen,  are  recorded  by 
Dr.  Southey,  from  congenital  constriction  of  the  gut,  at  the  point 
of  departure  of  diverticula,  the  remains  of  the  omphalo-uiesenteric 

duct.f 

Yery  frequently  the  diverticulum  itself  is  the  cause  of  mischiev- 
ous or  fatal  complications.  It  may  adhere  to  some  part  of  the 
abdominal  wall,  and  drag  the  intestine  to  such  an  extent  as  to 
completely  obstruct  it.  This  occurred  in  a  child  of  ten,  in  Dr. 
Wilk's  experience.:]:  Sometimes  the  diverticulum  becomes  ad- 
herent by  a  band  of  lymph  to  the  mesentery,  forming  a  loop  in 
which  a  knuckle  of  intestine  may  become  strangulated  ;  this  has 
been  observed  in  a  child  aged  four.§  In  other  cases  the  diverticu- 
lum may  become  filled  with  foreign  bodies,  or  undigested  food, 


*  Clin.  Soc,  Oct.  22d,  1880.  f  Trans.  Clin.  Soc,  vol.  v,  pp.  159-163. 

X  Trans.  Path.  Soc,  vol.  xvi. 

?  Holmes's  System  of  Surgery,  vol.  iv,  Art.  Diseases  of  the  Intestines,  by  George 
Pollock,  Esq.,  p.  610.      . 


INTESTINAL   OBSTRUCTION.  209 

and  fatal  obstruction  with  perforation  of  the  morbid  outgrowth 
may  ensue,  as  in  a  specimen  exhibited  before  the  Pathological 
Society.* 

Diverticula  may  become  perforated  in  typhoid  fever.f 

A  displaced  appendix  vermiformis  may  become  united  to  the 
bowel,  forming  a  band,  and  ultimately  causing  obstruction. 

Mr.  Pollock,  in  his  article  on  diseases  of  the  intestines,  in 
Holmes's  System  of  Surgery,  after  enumerating  the  signs  of  intus- 
susception, then  proceeds  to  describe  the  symptoms  of  these  rarer 
forms  now  under  our  consideration. 

"  In  all  internal  strangulations  by  bands,  etc.,  the  s^nnptoms  are 
generally  very  acute  ;  the  pain  is  sudden,  sharp,  even  agonizing 
occasionally^;  vomiting  sets  in  early,  and  is  usually  incessant;  the 
distension  may  not  be  as  great  as  in  the  more  slowly  operating 
causes  of  obstruction,  since  little  food  can  be  taken,  but  still  the 
small  intestine  becomes  much  loaded  ;  there  is  generally  great 
tenderness  on  pressure,  for  usually  peritonitis  is  not  long  absent ; 
there  is  early  evidence  of  grave  constitutional  damage,  for  the 
portion  of  intestine,  tightly  bound  down  or  encircled  at  the 
Rtrictured  part,  soon  thickens  and  inflames,  or  may  blacken  and 
mortify." 

As  for  chronic  obstruction,  the  physician  should  be  on  his  guard 
in  watching  all  disorders  in  which  it  .may  take  place.  It  often 
accompanies  intractable  tubercular  disease  of  the  peritoneum  in 
ill-fed  children. 

Treatment. — If  a  hernia  exists  and  can  be  discovered,  it  should 
be  reduced,  and  after  this  an  enema  of  oil  or  gruel  should  be 
employed.  If  the  symptoms  point  to  internal  strangulation,  and 
a  diagnosis  can  be  established,  the  abdomen  should  be  opened  that 
the  constricted  intestine  may  be  set  free.  If  any  abdominal  swell- 
ing points  to  fecal  accumulation  in  the  csecum,  or  large  intestine, 
enemata  of  castor  oil  and  poultices  to  the  abdon^en  should  be  used, 
and  it  may  be  necessary  sometimes  to  remove  the  hardened  masses 
from  the  rectum  with  a  scoop.  In  some  cases  of  abdominal  ob- 
struction attended  with  inflammatory  symiptoras,  it  may  be  neces- 
sary to  employ  a  few  leeches  to  the  abdomen,,  and.  give  full  doses 
of  opium  and  belladonna.:}: 

*  Trans.  Path.  Soc,  vol.  xxiii. 
t  The  Lancet,  November  10th,  1877. 
X  See  Chapter  XVII,  On  Constipation  and  Colic. 
14 


210  DISEASES   OF   CHILDREN. 

A  case  is  recorded  where  a  child  three  days  after  birth  had 
passed  no  motion.  As  the  linger  could  only  be  introduced  an  inch 
within  the  rectum,  the  case  was  looked  upon  as  one  of  imperforate 
anus,  and  an  operation  was  performed.  Two  days  later,  the  child 
died  from  peritonitis.  A  post-mortem  examination  showed  that 
the  obstruction  was  due  to  a  volvulus  situated  two  feet  above  the 
ileo-cEecal  valve.* 


CHAPTER    XIX. 

IXTUSSUSCEPTIOX — INVAGIXATIG^^. 

Meaning  and  Definition:  Two, forms  described — 1.  Simple  intussusception,  slight  or 
spasmodic — Case  in  illustration — 2.  Severe  or  inflammatory  forms.  Anatomical 
Appearances — Cattses  :  Diarrhoea  the  commonest  cause — Constipation — Blows  upon 
the  abdomen  or  sudden  jerks  on  the  body —  Weight  of  a  tumor  dragging  dov.m  part 
of  intestine.  Symptoms  :  Course  and  terminations — Persistent  vomiting  frequently 
present — Tenesmus  and  bloody  mvLCUs.  Diagnosis:  From  local  enteritis — Internal 
strangulation — Simple  colic — Vomiting — Amount  of  urinary  secretion  as  a  means 
of  diagnosis— Impacted  faeces — Typhlitis,  etc.  Treatment  :  Enemata — Inflation — 
Dangers  of  purgatives — Gastrotomy. 

IxvAGiisrATiox  belongs  particularly  to  infancy  and  early  life,  and 
is  one  of  those  disorders  that  demands  prompt  and  judicious  treat- 
ment. Fortunately  its  frequency  bears  no  relation  to  its  invariable 
painfulness  and  danger.  This  malady  essentially  consists  in  the 
passage  or  inversion  of  one  portion  of  intestine  into  another,  just 
in  the  same  way  as  one  tube  may  be  slipped  into  another,  or, 
what  is  a  better  illustration,  the  end  of  a  glove-finger  or  stocking 
pushed  within  the  upper  portion.  The  effect  of  this  invagination 
is  not  primarily  strangulation,  or  arrest  of  the  circulation,  but  ob 
struction  to  the  passage  of  the  intestinal  contents.  Sir  Thomas 
Watson  observes,  however,  that  "  the  containe^i^  portion  of  intes- 
tine is  liable  to  be  nipped  and  strangulated  by  the  coutalnm^  por- 
tion, and  all  the  peril  of  hernia  results,  with  much  less  chance  of 
relief  by  art.     This  state  of  things  is  called  intussusception."t 

Intussusception   may   be   divided   into:    1.   Simple,   slight,   or 
spasmodic  cases,  where  the  invaginated  intestine  has  not  been 


*  Brit.  Med.  Journ.,  vol.  i,  1880,  p.  7.38. 

f  Principles  and  Practice  of  Physic,  1857,  vol.  i,  p.  40. 


INTUSSUSCEPTION — INVAGINATION.  211 

sufficiently  irritated  to  become  inflamed.  2.  Severe  cases,  where 
the  involved  portion  has  inflamed  or  sloughed. 

The  first  variety  is  unattended  by  inflammation,  and  may  be 
considered  mainly  due  to  spasm.  A  good  example  of  this  will  be 
described  presently.  Slight  intussusceptions  have  been  found  in 
the  bodies  of  children  who  have  had  no  symptoms  of  such  displace- 
ment during  life,  and  who  have  died  from  other  forms  of  disease. 
Invagination  of  the  small  intestine  is  not  uufrequently  found  at 
the  autopsies  of  children  who  have  died  during  the  period  of  den- 
tition, or  from  diarrhoea,  without  any  symptoms  of  intussuscep- 
tion.* Billard  has  seen  it  in  cases  of  constipation,  and  Lewis 
Smith  in  infants  who  had  had  subacute  or  chronic  entero-colitis.f 
"  It  is  the  result  of  an  unequal  irritability  of  the  intestine,  and 
the  consequent  irregularity  of  its  movements,  and  it  is,  therefore, 
frequent  in  diseases  characterized  by  torpor  of  the  cerebro-spinal 
system,  and  in  the  mortal  agony  proceeding  from  them ;  whereas 
it  rarely  or  never  occurs  in  diseases  accompanied  by,  or  ending 
with,  abdominal  paralysis,  such  as  cholera,  typhus,  general  peri- 
tonitis, etc.":j: 

The  intussusception  in  some  cases  is  slight  enough  to  make 
it  probable  that  no  trace  of  inflammation  or  even  congestion  is 
present.  The  invaginated  mass  is  usually  from  half  an  inch  to 
two  inches  in  length,  and,  as  a  rule,  this  accident  is  multiple. 
There  may  be  ten  or  more  distinct  intussusceptions  at  distances  of 
a  few  inches  from  each  other.  In  the  museum  of  the  College  of 
Surgeons  there  is  a  specimen  of  a  portion  of  the  small  intestine  of 
a  child  four  j-ears  of  age,  in  which  three  intussusceptions  are  to  be 
seen  all  close  to  one  another.§ 

An  intussusception  involves  three  layers  of  intestine.  The  in- 
nermost consists  of  the  invaginated  upper  portion  of  intestine ;  its 
mucous  layer  is  internal  and  the  peritoneal  external.  The  middle 
or  inverted  portion  also  belongs  to  the  invaginated  segment,  and 
is  reflected  below  from  the  lower  limit  of  the  inner  layer,  and 
above  is  continuous  with  the  upper  margin  of  the  outer  layer. 
From  its  inversion  the  mucous  membrane  lies  external  to  its  peri- 

*  Meigs  and  Pepper,  Diseases  of  Children,  art.  vi,  Intussusception,  p.  463. 
t  Lewis  Smith  on  Diseases  of  Children,  Philadelphia,  1869,  p.  419. 
X  Roliitansky,  Path.  Anatomy,  1849,  vol.  ii,  p.  54,  translated  by  E.  H.  Sieveking, 
M.D. 

I  No.  1365,  Pathological  series. 


212  DISEASES    OF    CHILDEEX. 

toneal  coat.  The  outer  layer  consists  entirely  of  that  portion  of 
intestine  into  which  the  former  two  have  intruded  themselves. 
Above  it  is  reflected  upon  the  middle  layer,  with  which,  in  fact,  it 
is  there  continuous.  Its  mucous  surface  is  innermost,  facing  tliat 
of  the  middle  layer,  "  The  inverted  portion  is  invariably  the  one 
that  sutfers  most ;  the  inflammation  of  the  entering  tube  is  less 
considerable,  and  it  is  characteristic  that,  even  when  the  inflam- 
mation of  the  volvulus  runs  high,  its  mucous  membrane  remains 
pale  ;  the  sheath  of  the  volvulus  also  is  but  slightly  affected  in 
small  intussusceptions,  with  the  exception  of  the  peritonitis  at  the 
point  where  it  enters."*  "The  vessels  of  the  portion  of  intestine 
thus  incarcerated  become  engorged  and  render  the  obstruction 
complete  ;  the  whole  of  the  folds  involved  become  swollen  and 
deeply  congested ;  blood  is  extra vasated  into  the  substance  of  the 
mucous  membrane  as  well  as  into  the  mesentery  ;  in  a  short  time 
both  the  serous  and  mucous  surfaces  become  inflamed  and  the 
efi"usion  of  lymph  takes  place ;  the  opposed  serous  surfaces  become 
adherent,  and  also,  to  a  less  degree,  the  mucous  surfaces;  bloody 
serum  and  mucus  are  eftused  into  the  canal,  and  this  discharged 
per  rectum  is  very  diagnostic  of  intussusception. "f 

The  following  I  consider  to  have  been  a  typical  case  of  the 
spasmodic  variety,  unattended  by  peritonitis,  or  actual  constric- 
tion, and  terminating  in  complete  recovery. 

E.  S ,  set.  2  years  and  9  months,  was  first  seen  by  me  on 

January  4th,  1875,  at  10  a.m.,  having  been  in  good  health  the 
previous  day.  She  was  an  intelligent  and  precocious  child.  I 
found  her  in  bed,  very  flushed  and  excited,  skin  hot,  but  sweating. 
Temp.  103°,  pulse  160,  respirations  quick  and  shallow.  .  She  lay 
with  her  legs  extended,  and  bore  pressure  over  the  abdomen  with 
the  hand  without  complaining.  The  belly  was  rather  tympanitic, 
and  the  bowels  constipated  ;  they  had  acted  scantily  on  both  the 
two  previous  days  ;  there  was  thirst,  but  no  vomiting.  The  child 
was  allowed  to  drink  a  little  milk  and  iced  water  at  intervals  to 
allay  thirst.  The  abdomen  was  fomented,  and  half  a  grain  of 
calomel  ordered  every  four  hours,  together  with  citrate  of  potash. 
January  5th  (10  a.m.). — The  child  had  been  sick  once,  and  the 
bowels  not  having  acted,  her  mother  used  a  simple  enema  of  warm 
water,  which  returned  as  injected.    She  cried  out  occasionally  with 

*  Rokitansky,  Path.  Anatomy,  p.  57. 

•j-  On  Diseases  of  the  Alimentary  Canal,  by  S.  O.  Habershon,  M.D.,  1857,  p.  316. 


INTUSSUSCEPTION — INVAGINATION,  213 

pain,  but  no  distension  or  tumor  can  be  felt.  Has  taken  two 
powders,  and  kept  both  down.  The  sixth  of  a  grain  of  calomel, 
with  one  grain  of  Dover's  powder,  was  ordered  every  four  hours. 
(7  P.M.).  Dozing,  and  no  return  of  sickness.  Having  passed  no 
urine,  a  gum  elastic  catheter  was  introduced,  and  six  ounces  of 
clear  urine  drawn  off. 

6th  — A  good  deal  of  tenderness  over  stomach  and  neighborhood 
of  nmbilicus,  but  no  vomiting.  Eight  ounces  of  warm  soap  and 
water  were  thrown  up  the  bowels,  which  brought  away  a  little 
feculent  matter.  A  carminative  mixture  of  rhubarb,  aromatic 
spirit  of  ammonia,  and  peppermint-water  were  substituted,  and 
ordered  every  four  hours  in  place  of  the  powders. 

7th  (10  a.m.). — The  bowels  not  having  acted,  and  there  being  no 
certainty  of  obstruction,  I  gave  a  lozenge  of  scammony  and  gr.  ^ 
of  calomel,  which  had  the  eftect  of  causing  considerable  pain  and 
uneasiness,  without  producing  any  evacuation.  The  child  again 
could  not  pass  urine,  and  on  that  account  a  catheter  was  intro- 
duced into  the  bladder,  and  seven  ounces  of  clear  acid  urine  drawn 
off.  The  finger  inserted  into  the  rectum  was  unstained  by  fecal 
matter.  I  now  determined  to  keep  the  bowels  at  perfect  rest,  and 
ordered  the  following  mixture : 

R.    T.  belladonnpe, ttjJvj 

Spt.  chloroform, ^vij 

Acid,  hj'drocy.  dil , fi^vj 

Syriipi,  .........  ,5ss. 

Aquam  ad ^iss. — M. 

3ij  every  four  hours. 

(3.30  P.M.).  The  child  was  disposed  to  be  drowsy,  and  the  mus- 
cular system  was  much  relaxed;  great  tympanites  over  stomach, 
and  above  line  of  umbilicus,  but  nothing  marked  over  either  iliac 
fossa;  lips  rather  dry,  and  tongue  creamy;  has  kept  down  milk 
and  water  and  beef  tea  during  the  day.  Urine  again  drawn  off, 
less  in  quantity  and  deeper  in  color,  sp.  gr.  1020,  reaction  acid, 
faint  cloud  on  heat,  and  nitric  acid.  (8  p.m.)  Mr.  Stephens,  of 
Hoddesden,  and  Dr.  Habershon,  joined  me  in  consultation.  We 
considered  the  symptoms  due  to  intussusception,  though  no  cause 
could  be  ascertained  beyond  a  sudden  change  to  a  more  luxurious 
and  mixed  diet  than  the  child  was  accustomed  to  at  home.  Rest- 
lessness and  refusal  of  the  bowels  to  act  (notwithstanding  the 
remedies  tried)  were  the  chief  symptoms.     Three  grains  of  the 


214  DISEASES    OF    CHILDEEN. 

bicarbonate  of  soda  were  added  to  each  dose  of  the  mixture. 
Four  ounces  of  urine  drawn  off.  A  copious  warm  soap-and- water 
enema  was  thrown  into  the  rectum,  and  three  or  four  small 
scjbalre  came  away,  which  could  not  be  detected  in  the  morning. 
Dr.  Habershou  thought  the  belladonna  had  brought  them  down. 
He  considered  that  a  portion  of  the  ileum  had  slipped  into  the 
ccecum ;  but  my  first  impression  was,  from  the  twisting  umbili- 
cal pain,  and  the  absence  of  any  lump  or  dulness  in  either  iliac 
region,  that  the  displacement  (if  any  really  existed)  took  place 
between  the  lower  j^ortion  of  the  jejunum  and  the  upper  part  of 
the  ileum.  The  paralysis  of  the  bladder  must  have  arisen  from 
sympathetic  irritation. 

8th  (10  A.M.). — iSo  action  of  the  bowels  or  sickness  ;  has  passed 
a  little  urine.  At  the  upper  constricted  part  of  the  rectum  (left 
sacro-iliac  symphysis)  I  felt  something  hard  protruding  through  it 
for  about  an  inch,  and  between  the  rectum  and  bladder  at  its  upper 
part  was  an  elastic  fulness,  which  I  considered  to  be  a  distended 
convolution  of  small  intestine.  An  O'Beirne's  tube,  well  oiled, 
was  passed  up  gradually  into  the  descending  colon  without  meet- 
ing with  any  resistance.  An  enema  of  sixteen  ounces  of  warm 
soap-and-water,  with  two  ounces  of  infusion  of  rhubarb,  was  then 
injected,  and  it  speedily  returned  as  thrown  up.  Shortly  after  this, 
a  repetition  of  the  enema  brought  down  a  mass  of  feculent  matter 
four  inches  in  length  ;  and  by  continuing  to  wash  out  the  rectum, 
the  fulness  much  diminished  behind  the  bladder.  A  warm  poul- 
tice was  applied  to  the  abdomen,  and  the  belladonna  mixture 
continued.  (10  p.m.)  jN^o  further  action  of  the  bowels  ;  rectum 
empty. 

9th. — In  uneasy  sleep,  waking  up  at  intervals  in  pain  and  dis- 
comfort ;  the  tympanites  was  less  over  the  stomach,  and  the 
margins  of  the  ribs  could  be  distinctly  seen  over  the  hypochon- 
dria ;  i^ain  referred  to  hypogastrium,  but  no  tumor  could  be  felt ; 
has  passed  a  little  urine  ;  injection  repeated,  followed  by  the  escape 
of  a  few  small  scybaUie.  Pulv.  Ipecac.  Co.  gr.  iss.  to  be  given  every 
four  hours,  if  in  pain. 

10th. — A  few  scybalous  masses  came  away  after  an  injection  of 
warm  w'ater. 

11th. — Rectum  empty.  Half  an  ounce  of  warm  linseed  oil 
thrown  into  the  rectum.  Has  passed  water  three  times  since 
yesterday. 


INTUSSUSCEPTION — INVAGINATION.  215 

12th. — During  the  latter  part  of  yesterday  there  were  three 
scanty  actions  of  the  bowels,  with  considerable  pain  for  three  or 
four  hours.  Twelve  ounces  of  warm  soap-and-water  were  injected, 
which  returned  untinged  Avith  fiBces,  An  ounce  of  warm  linseed 
oil  was  therefore  thrown  into  the  bowel. 

13th. — The  abdomen  was  more  tympanitic,  and  painful  at  the 
lower  part.  She  passed  water  freely,  and  there  was  tenesmus,  but 
no  motion ;  pulse  112,  weak  and  thready.  I  thought  this  increase 
of  pain  and  swelling  might  be  owing  to  the  bowel,  after  recovery 
from  the  invagination,  again  slipping  down  into  its  old  position. 
A  few  drops  of  brandy  ordered  in  a  little  thin  arrowroot  every 
three  hours. 

14th. — A  very  slight  oozing  of  fecal  matter. 

15th. — Bowels  moved  slightly  three  times. 

16th. — From  10.30  till  12.30  last  night  she  was  most  uncom- 
fortable, after  which  she  passed  a  dark-green  liquid  motion.  At 
2  A.M.,  one  copious  but  less  dark  motion,  at  3  a.m.,  one  of  a  bright- 
yellow  color,  all  being  attended  with  pain  of  a  griping  twisting 
character;  at  11  a.m.  there  was  a  rather  lumpy  action  of  the 
bowels  ;  at  8.30,  11.30,  and  12  p.m.  a  liquid  motion,  so  that  it  w^as 
evident  from  the  quantity  that  had  passed,  there  must  have  been 
accumulation  beyond  the  immediate  reach  of  enemata. 

17th. — A  soft  motion  was  passed  this  morning,  when  the  child 
shrieked  out  with  more  pain  than  she  had  felt  before,  and  clasped 
her  mother  ;  the  pain  was  referred  to  the  umbilicus,  but  only  a 
slight  degree  of  tympanites  could  be  detected  in  this  situation. 
Though  this  escape  of  fecal  matter  might  have  been  sufficient  to 
irritate  the  bowels  and  produce  pain,  it  was  possible  that  a  portion 
of  intestine  had  become  iuvaginated  or  twisted  from  time  to  time, 
or  the  pain  was  due  to  the  bowels  being  thrown  into  commotion, 
causing  irregular  contraction  or  spasm,  by  their  freer  action.  Two 
grains  of  the  Pulv.  Ipecac.  Co.,  and  the  sixth  of  a  grain  of  calomel, 
were  ordered  every  two  hours  if  in  pain. 

18th. — Had  seven  hours'  sleep.     Took  two  powders. 

19th. — BoAvels  open  four  times. 

20th. — Bowels  acted  twice — a  good  night. 

21st. — Bowels  moved  twice.     Went  to  her  home  in  the  country. 

April  10th. — Mr.  Stephens  reported  that  the  journey  home  threw 
the  child  back  a  month,  and  enemata  were  required  every  third 
day,  in  order  to  act  on  the  bowels.     There  were  tenderness  and 


216  DISEASES    OF    CHILDREN. 

tympanites,  and  only  small  scybalous  motions  were  evacuated. 
For  a  long  time  after  her  return  home  the  temporal  fossae  were 
greatly  sunken,  and  the  skin  was  like  vellum  from  the  absorption 
of  fat. 

January,  1876. — For  some  three  months  past  the  child  had  been 
quite  well. 

In  this  case  the  degree  of  constriction  was  too  slight  to  entirely 
prevent  the  passage  of  the  intestinal  contents,  and  the  chief  danger 
lay  in  death  from  exhaustion  rather  than  from  obstruction.  The 
normal  vermicular  movement  of  the  intestines  in  these  slight  cases 
has  the  effect  of  restoring  the  invaginated  gut  to  its  proper  place, 
when  rest  and  aj^propriate  measures  are  adopted. 

The  second  variety  of  intussusception  is  that  which  chiefly  con- 
cerns us,  by  producing  very  positive  and  umistakable  symptoms, 
in  addition,  in  some  cases,  to  a  defined  abdominial  tumor,  and 
the  partial  protrusion  of  the  invaginated  intestine  (sausage-like  in 
shape)  into  the  rectum,  within  reach  of  the  surgeon's  finger. 

A  mass  of  coagula  may  be  mistaken  for  an  intussusception,  as 
in  a  case  recorded  hy  Mr.  Morris,  in  the  twentj^-eighth  volume  of 
the  Path.  Soc.  Irans.,  where  an  intussusception  of  the  ileum  ac- 
tually existed,  but  this  did  not  involve  the  large  intestine,  which 
was  full  of  clots. 

In  genuine  intussusception,  it  is  the  upper  segment  of  the  bowel 
that  is  almost  invariably  forced  into  the  lower  Brinton  doubted 
whether  the  contrary  can  ever  occur.  Ascending  intussusception,* 
however,  is  spoken  of  by  some  writers.!  Handfield  Jones  and 
Herbert  Page  describe  a  case  where  both  varieties  coexisted,  and 
"  the  extremities  of  the  two  intussusceptions  overlapped  each 
other.":j: 

The  proportion  of  frequency  with  respect  to  age  goes  to  show, 
that  of  twelve  specimens  in  children  noted  in  the  Museum  of  the 
College  of  Surgeons,  two  were  aged  respectively  four  years,  one  a 
year  old,  and  none  of  the  remainder  exceeded  ten  months. 

The  proportions  of  frequency  in  the  different  parts  of  the  canal 

*  In  the  Museum  of  tlie  College  of  Surgeons  is  a  specimen  of  a  cat's  intestine,  willi 
an  ascending  or  retrograde  intussusception  close  to  one  of  the  ordinary  variety. 

t  Meigs  and  Pepper,  p.  4G3. 

X  A  Case  of  Intussusception  in  whicli  Abdominial  Section  was  performed,  Med. -Cliir. 
Trans.,  vol.  Ixi. 


INTUSSUSCEPTIOX — INVAGIXATIOX.  217 

which  are  liable  to  this  displacement  are  as  follows,  according  to 
Brintou  :* 

Ileum  and  csecum  into  large  intestine,  56  per  cent. 

"Half  the  large  class  of  ileo-cfecal  intussusceptions  are  infants 
under  seven  years  of  age,  many  but  a  few  months  old." 

"  Small  intestine  invaginated  into  a  lower  part  of  small  intes- 
tine, 32  per  cent." 

Colon  intussuscepted  into  itself,  12  per  cent.  (According  to 
E.okitansk}'-,  however,  "Intussusceptions  occur  with  equal  fre- 
quency in  the  colon  and  small  intestine.") 

"  The  rectum  scarcely  ever  forms  more  than  the  outer  layer  of 
an  intussusception  which  has  descended  into  it  from  above." 

Brinton  believes  that  the  sloughing-off  of  an  intussusception  is 
not  complete  on  an  average  before  the  eighth  day,  and  the  liber- 
ated bowel  is  not  expelled  till  two  days  later ;  "  and  as  the  intus- 
susception, where  primarily  fatal,  mostly  kills  in  about  five  days 
and  a  half,  we  may  fairly  conjecture  that  the  casting  loose  of  the 
invagination  is  sometimes  only  prevented  by  the  death  of  the  pa- 
tient." (Brinton.) 

The  average  duration  of  the  cases  directly  fatal,  appears  to  be 
the  same  in  the  different  varieties,  five  days  and  a  half. 

Anatomical  Appearances. — There  are  numerous  specimens  of  in- 
tussusception at  the  Museum  of  the  College  of  Surgeons,  showing 
the  direction  which  the  displaced  intestine  takes.  In  nearly  all 
cases  from  the  human  subject,  it  is  of  the  descending  variety,  or 
in  a  direction  downwards. 

In  infants,  the  lower  end  of  the  ileum  suffers  most  frequently. 
This  is  ow'ing  partly  to  the  looseness  of  the  attachment  of  the 
caecum  in  the  right  iliac  fossa,  and  the  imperfect  development  of 
its  muscular  coat  in  early  life,  which  allows  the  ileum  to  slip 
through  the  valve. 

Causes. — Intussusception  in  very  young  children  may  arise  from 
many  disorders  of  the  alimentary  canal,  especially  diarrhoea ;  in- 
deed, this  is  a  common  cause  in  infants  ;  even  in  older  children, 
diarrhcea,  muco-enteritis,  and  dysenteric  discharges  are  capable  of 
originating  the  complaint.  In  a  large  number  of  cases  it  cannot 
be  denied  that  derangement  of  the  functions  of  the  intestinal 
viscera  precedes  the  displacement,  and  since  it  happens  so  fre- 

*  Intestinal  Obstruction,  by  Wm.  Brinton,  M.D.,  F.E.S.,  edited  by  T.  Buzzard,  M.D. 


218  DISEASES    OF    CHILDREN. 

qnentl}^  to  j'oung  children,  it  may  be  accepted  as  a  certainty,  that 
irregular  contraction  of  these  viscera  from  the  ingesta  is  a  common 
cause  of  the  disorder.  "  The  cause  of  this  abnormal  involution 
appears  to  be  sudden  and  spasmodic  contraction  of  a  portion  of  in- 
testine, impelled,  onwards  into  a  portion  less  contracted  or  alto- 
gether flaccid.  It  occurs  at  all  periods  of  life,  but  perhaps  is  more 
frequent  in  youth  and  infancy."* 

Of  52  Qases  tabulated  by  Dr.  Lewis  Smith,  the  health  was  re- 
corded before  the  invagination  in  34 ;  of  these  34,  the  previous 
health  was  good  in  17,  and  deranged  in  17  ;  the  previous  health 
in  most  of  the  17  consisted  of  diarrhoea  or  dysentery,  or  diarrhoea 
alternating  with  constipation  ;  others  had  threadworms,  obscure 
abdominal  pains,  nausea,  and  vomiting.  One  child  had  symptoms 
of  invagination  at  ten  weeks  old,  which  passed  off.f 

The  male  sex  is  most  liable  to  the  complaint,  and  of  34  cases, 
23  were  boys.     (Lewis  Smith.) 

The  liability  of  young  children  to  the  disorder  is  in  a  great 
measure  due  to  the  delicate  structure  of  the  walls  of  the  intestines, 
which  are  imperfectly  developed  in  infancy,  and  to  unsteadiness  in 
their  movements. 

It  is  not  proved  that  intussusception  is  due  to  congenital  laxity 
of  the  mesoccTecum  or  mesocolon. 

Among  the  exciting  causes,  blows  and  contusions  of  the  abdo- 
men have  produced  diarrhoea  and  constipation,  followed  by  in- 
vagination ;  violent  fits  of  screaming,  and  straining  at  stool  have 
induced  the  complaint.  Tossing  the  child  up  in  the  arms  suddenly 
with  a  jerk,  and  then  bringing  it  quicklj^  to  the  ground,  may  cause 
intussusception.     (Rilliet  and  Barthez.) 

The  simple  form  of  intussusception  is  usually  situated  in  the 
small  intestines,  and  very  rarely  in  the  colon ;  m  the  more  aggra- 
vated form  the  ileum  is  general!}'  invaginated  into  the  colon.  The 
latter  is,  as  Brinton  has  shown,  the  most  frequent. 

The  bowels  may  act  as  many  as  four  or  five  times  a  day,  and  the 
child  die  notwithstanding,  and  after  death  the  invaginated  intes- 
tine may  be  from  one  to  two  feet  long.  The  bowels  may  remain 
pervious  for  weeks,  and  then  death  ensue. 

Sy)apioms. — These  vary  in  severity  according  to  the  age  of  the 
child  and  the  cause  which  may  have  produced  it,  but  griping  par- 

*  Haberslion,  op.  cit.,  p.  318. 

t  Lewis  Smith,  op.  cit.,  1869,  p.  420. 


INTUSSUSCEPTION — INVAGINATION.  219 

oxysmal  pain,  pallor,  faintness,  and  constipation,  are  common  in 
most  cases,  increasing  after  a  few  days  when  enteritis  is  estab- 
lished. At  first,  as  in  the  case  of  simple  invagination  related, 
pressure  is  borne  by  the  hand,  and  the  little  patient  may  have  com- 
fortable snatches  of  sleep ;  but  if  the  invagination  continues,  the 
symptoms  assume  a  more  aggravated  form,  and  inflammation, 
marked  by  great  abdominal  pain,  vomiting,  and  tenesmus,  arises 
in  the  displaced  portion  of  intestine.  If  the  child  is  very  young, 
convulsions  may  supervene,^"  and  even  if  this  complication  does 
not  arise,  the  child  soon  loses  flesh,  the  face  is  pinched  and  hag- 
gard, and  the  eyes  dark  and  sunken.  Vomiting  is  a  frequent  symp- 
tom, and  cases  are  rare  where  it  is  not  present ;  at  first  the  con- 
tents of  the  stomach  are  simply  rejected,  and  afterwards  the  ejecta 
are  grass-green,  and  ultimately  become  stercoraceous,  as  in  the 
well-known  vomiting  in  cases  of  strangulated  hernia.  After  a  day 
or  two,  the  bowels  generally  cease  to  act,  and  a  few  more  scanty 
evacuations  will  not  in  these  cases  prove  that  the  bowels  are  not 
obstructed,  for  the  excrementitious  matters  may  issue  from  below 
the  seat  of  obstruction.  These  scanty  motions  are  generally  tinged 
with  blood,  including  much  mucus,  and  are  very  characteristic. 
But  as  Mr.  Marsh  has  pithily  remarked  in  regard  to  the  case  of  a 
young  child  in  his  own  experience,  "intussusception,  even  though 
it  involves  a  considerable  length  of  intestine,  does  not  necessarily 
produce  any  symptoms  beyond  those  that  commonly  attend  slight 
catarrhal  enteritis.  The  development  of  symptoms  depends  upon 
the  degree  of  constriction.  In  this  respect  an  intussusception  is 
like  a  hernia,  which  may  be  '  down '  without  being  strangulated 
or  even  obstructed.  And  to  say  that  vomiting,  constipation,  and 
the  discharge  of  blood  and  niucus  or  serum  from  the  bowel  are 
the  symptoms  of  invagination  is  inexact,  in  the  same  sense,  in 
which  it  would  be  to  say  that  vomiting  and  constipation  are  symp- 
toms of  hernia. "f 

A  solid  cylindrical  tumor  may  generally  be  detected  by  careful 
examination.  It  is  most  frequently  found  in  the  right  iliac  or 
hypogastric  regions,  sometimes  it  can  be  felt  by  passing  the  finger 

*  Dr.  Habershon  records  a  case  of  intussusception  where  convulsions  and  insensi- 
bility followed  constipation,  vomiting,  and  pain  in  the  abdomen,  in  a  boy  six  years  of 
age.  Notwithstanding  that  he  passed  the  cfecum,  together  with  the  vermiform  process 
and  ascending  colon,  in  a  motion,  he  completely  recovered. — Op.  cit.,  p.  337. 

t  A  Case  in  which  Abdominal  Section  was  performed  for  Intussusception,  St.  Earth. 
Hosp.  Eep.,  vol.  xii. 


220  DISEASES    OF    CHILDREN. 

up  the  rectum,  but  it  may  be  obscured  by  tympanites  due  to  the 
enteritis  which  it  produces.  When  it  can  no  longer  be  distin- 
guished after  having  once  been  detected,  it  may  have  shifted,  but 
more  frequently  it  has  sloughed  off. 

Diagnosis. — In  endeavoring  to  form  a  right  conclusion  as  to  the 
cause  of  the  symptoms  of  obstruction,  we  must  not  hastily  infer 
that  they  arise  from  intussusception.  "  I  admitted  into  St.  George's 
Hospital,  some  years  ago,  a  little  child  who  had  many  of  the 
sj-mptoms  of  intussusception, — obstinate  constipation,  straining  to 
go  to  stool,  occasional  vomiting,  and,  it  was  said,  a  bloody  dis- 
charge from  the  anus  occasionally ;  and  in  whom  there  was  also 
to  be  felt  a  kind  of  oblong  tumor,  somewhat  tender  to  the  touch, 
at  one  part  of  the  abdomen.  All  this  rather  pointed  to  intussus- 
ception, but  the  course  of  the  disease  convinced  me  that  the  cause 
of  the  obstruction  was  really  (as  I  believe  it  \eYj  often  is)  limited 
peritonitis,  producing  adhesion  or  impaction  of  neighboring  coils 
of  intestine."*  It  may  be  impossible  to  distinguish  the  vomiting, 
feeble  pulse,  tympanites,  and  worn  look  from  local  enteritis  or  in- 
ternal strangulation,  but  when  mucus  and  blood  are  passed  per 
anum,  it  greatly  assists  the  diagnosis.  "  The  sudden  onset  of  the 
pain,  and  its  subsidence,  becoming  aggravated  in  paroxysms,  is  an 
indication  of  this  form  of  obstrnction."f  The  symptoms  often 
commence  insidiously,  and  are  so  puzzling  that  the  ripest  judg- 
ment may  be  deceived.  It  may  be  mistaken  for  enteritis,  but  the 
historj'-  should  come  to  our  assistance,  the  temperature  and  febrile 
excitement  are  not  so  great,  and  the  colicky  pain  is  more  parox- 
ysmal and  severe.  "  In  contrast  to  simple  colic  the  spasm  is  more 
regular  in  its  recurrence,  there  is  less  sensation  of  twisting  and 
grinding,  and  more  of  a  continued  paroxysm,  caused  by  the  violent 
and  energetic  action  of  the  muscular  fibre  to  overcome  the  ob- 
struction ;  the  large  coils  of  intestine  may  sometimes  be  felt  rolling 
and  turning  over  in  the  abdomen  during  its  continuance.":]: 

"  The  movements  and  throes  of  intestinal  obstruction,  added  to 
the  pain  and  intense  constitutional  reaction  of  enteritis,  form,  in 
the  earlier  stages  of  intussusception,  a  concurrence  of  sjnnptoms 
60  characteristic  of  this  state  as  often  hardly  to  require  the  detec- 
tion of  the  swelling  produced  by  the  invaginated  bowel."  (Brinton  ) 

*  IIolmeK's  Surgical  Treatment  of  Children's  Diseases,  1868,  p.  509. 

t  Ilabershon,  op.  cit.,  p.  318. 

X  Medical  Diagnosis,  by  Dr.  Barclay,  ISoO,  p.  4(30. 


INTUSSUSCEPTIOIS^ — INVAGINATION.  221 

Let  it  also  be  borne  in  mind  that  in  forming  a  diagnosis  we 
should  recollect  that  hardened  and  impacted  feeces,  typhlitis, 
haemorrhage,  dysentery,  peritonitis,  and  cholera  infantum  may  all 
be  mistaken  for  the  condition  we  are  describing  ;  and  that  the 
symptoms  belonging  to  each  of  these  states  must  be  carefully  ob- 
served and  compared,  for  the  diagnosis  is  not  unattended  with 
difficulty. 

When  the  obstruction  is  high  up  in  the  intestinal  tube  the 
urinary  secretion  is  more  scanty  than  when  it  is  situated  lower 
down;  but  this  symptom  cannot  be  much  relied  on.  "Still  less 
reliance  is  to  be  placed  on  the  allegation  that  vomiting  comes  on 
earlier,  and  is  more  distressing  when  the  obstruction  is  high  up. 
.  .  .  .  "We  incline  to  believe  the  cause  of  the  obstruction  to 
be  invagination  if  a  little  bloody  mucus  be  passed  by  stool,  if  a 
sudden  pain  were  felt  before  vomiting  had  been  experienced,  and 
when  constipation  had  not  been  known  to  exist."* 

Intussusception  may  end  fatally  in  a  few  days,  or  terminate  in 
recovery  in  three  weeks.  In  infants  the  disease  is  ahiiost  invari- 
ably fatal. 

Intussusception  of  tbe  small  intestine  is  readily  distinguished 
from  the  ileo  cfecal  and  colic  forms. 

Small  intestine  alone  involved.  Ileo-CEecal  form  and  colic  form. 

1.  Little  or  no  tenesmus.  1.  Much  tenesmus. 

2.  Much  hfemorrhage  by  stool  and  vomit.  2.  Simple  blood-staining  of  motions. 

3.  Symptoms  of  obstruction  very  early.  3.  Obstruction  late  or  absent. 

4.  Tumor  small  and  movable.  4.  Tumor  large,  more  fixed,  easy  to  feel. 

5.  Invagination  not  felt  per  rectum.  6.  Invngination  often  detected  per  rectum. 

Sloughing  and  expulsion  of  the  intussusception  is  most  frequent 
when  the  small  intestine  alone  is  involved.  Recovery  too  is  far 
more  frequent  in  that  variety  than  in  ileo-ctecal  or  colic  intussus- 
ceptions. 

Treatment.  —  This  is  medical^  mechanical.,  and  operative.  Tlie 
symptoms  in  many  cases  at  the  onset  are  too  obscure  to  indicate 
with  anything  approaching  certainty  the  lesion  w^e  have  to  en- 
counter. Mucous  discharges  from  the  bowel,  vomiting,  tenesmus, 
and  the  escape  of  blood  are  not  conclusive  signs.  Even  diarrhoea 
and  intestinal  derangement,  which  more  properly  belong  to  an 
irritated  rather  than  to  a  displaced  intestine,  may  be  present  in 
cases  of  intussusception. 

*  Barclay,  op.  cit.,  p.  463. 


222  DISEASES   OF   CHILDREN. 

Whenever  sj-mptoms  of  obstruction  of  the  bowels  present  them- 
selves in  a  young  child,  Ave  should  not  overlook  the  possibility  of 
intussusception.  ^Vhen  the  seizure  is  sudden,  and  displacement 
is  considered  no  longer  doubtful,  we  may  adopt  remedies  with  some 
chance  of  success.  If  there  be  a  tumor  in  the  abdomen  with 
localized  tenderness,  two  or  three  leeches  may  be  applied  over  the 
spot. 

If  there  be  no  sickness  at  the  beginning,  and  constipation  be  the 
chief  feature  of  the  complaint,  a  dose  of  castor  oil  may  be  neces- 
sary, and  warm-water  enemata ;  but  if  these  should  fail  to  move 
the  bowels  it  is  no  longer  advisable  to  continue  them,  but  to  sub- 
stitute in  their  places  remedies  of  a  soothing  and  sedative  charac- 
ter. The  intestines  may  be  kept  at  rest  by  opium  in  small  and 
repeated  doses,  and  fomentations  to  the  abdomen  may  be  used,  or 
a  warm  bath.  The  opium  will  often  alia}'  the  distressing  sickness 
which  is  present,  and  iced  water,  ice  to  suck,  or  hj'drocyanic  acid 
will  all  be  useful.  Sometimes  a  small  mustard  poultice  to  the  pit 
of  the  stomach  will  stop  the  sickness. 

The  chief  aim  of  the  medical  treatment  consists  in  the  most 
absolute  repose  and  the  simplest  diet,  that  the  intestines  may  be 
kept  free  from  commotion,  and  bulky  matters,  the  refuse  of  diges- 
tion, may  not  enter  them.  Under  this  plan  the  bowels  have,  after 
many  days,  often  gradually  righted  themselves. 

The  mechanical  treatment  consists  in  the  forcible  injection  of 
copious  enemata  of  warm  water,  soap-aud-water,  or  thin  gruel. 
This  simple  measure  is  often  successful,  for  where  the  intussus- 
ception takes  place  between  the  ileum  and  crecum  (as  it  frequently 
does),  the  fluid  may  pai^s  beyond  the  valve  into  the  ileum,  and 
overcome  the  resistance.  Another  plan  is  to  pour  warm  water 
through  a  funnel  at  a  varying  height,  according  to  the  force 
required.  A  piece  of  india-rubber  tubing,  about  two  yards  long, 
is  attached  by  one  extremity  to  the  funnel,  and  by  the  other  to  a 
tube,  which  is  inserted  into  the  rectum.  I  have  recorded  a  very 
interesting  case,  successfully  treated  in  this  manner.* 

Inflation  by  means  of  air  has  been  used  successfully  since  the 
time  of  Hii^pocrates,  and  it  is  doubtful  whether,  in  these  modern 
times,  it  is  practiced  as  often  as  it  ought  to  be ;  for  when  it  has 


*  Intestinal  Obstruction  in  a  Child  :  Treatment  by  Belladonna  and  Gradual  Injec- 
tion of  Warm  Water  poured  into  the  Rectum  tlirough  a  Funnel  and  India-rubber  Tub- 
ing; Recovery.     By  W.  li.  Day,  M.D.,  Brit.  Med.  Journ.,  May  31st,  1879. 


INTUSSUSCEPTION — INA^AGINATION.  223 

been  employed  in  children,  many  cases  are  recorded  where  the 
resistance  has  been  overcome.  A  pair  of  ordinary  bellows  may  be 
used,  the  nozzle  introduced  into  the  rectum,  and  the  inflation 
proceeded  vi'ith  till  the  obstruction  yields. 

The  surgical  treatment  consists  in  performing  the  operation  of 
gastrotomy,  when  all  other  measures  have  proved  unavailing.  The 
circumstances  of  each  particular  case  must  be  carefully  weighed — 
the  urgency  of  the  symptoms,  and  the  strength  of  the  patient ;  the 
probability  of  inflamniation,  and  the  prospect  of  alighting  on  the 
seat  of  mischief.  From  what  we  have  learned  of  late  years  respect- 
ing the  tolerance  of  the  peritoneum  to  local  injury,  and  with  what 
impunity  it  may  be  liandled  without  exciting  inflammation,  there 
is  reason  to  think  that  the  lives  of  many  children  might  have  been 
saved  if  the  operation  had  not  been  too  long  delayed. 

Many  writers,  however,  are  of  opinion  that  this  treatment  is 
attended  with  too  much  risk  to  justify  the  step,  because  there  is 
diificulty  in  ascertaining  the  seat  of  obstruction,  and  even  if  found, 
the  operation  is  attended  with  extreme  danger.  If  a  tumor  can 
be  felt  in  the  left  iliac  fossa,  where  the  intussusception  frequently 
is  located,  there  is  a  fair  chance  of  localizing  the  constriction,  and 
the  operator  has  not  to  search  at  all  parts  of  the  intestinal  tube. 
Besides,  the  distance  to  which  enemata  travel  may  aid  the  diag- 
nosis. It  seems  certain  that  if  the  operation  holds  out  any  chance 
of  success,  it  should  not  be  delayed  over  three  or  four  days  when 
the  symptoms  are  severe  ;  because  the  invaginated  bowel  may 
inflame  and  contract  adhesions  with  the  surrounding  parts.  "  Only 
three  cases  collected  by  Haven,  in  which  gastrotomy  was  per- 
formed, terminated  favorably."* 

The  two  following  are  examples  of  gastrotomy,  one  fatal,  and 
one  successful. 

Case  1. — Mr.  Hutchinson  has  described  an  interesting  case  of  a 
child  six  months  old  on  whom  he  operated.  The  child  was  under 
the  care  of  Dr.  Madge,  and  had  been  ill  four  days  when  he  saw  it, 
with  painful  straining  and  the  passage  of  bloody  mucus.  "  The 
invaginated  part  could  be  easily  felt  in  the  left  flank  by  manipula- 
tion through  the  abdominal  wall,  and  also  by  the  finger  introduced 
into  the  rectum."  (An  infant  sister  died  a  year  previously  of  the 
same  lesion.)  The  intussusception  had  begun  in  the  csecum,  and 
at  the  post-mortem  next  day  there  was  universal  peritonitis,  and 

*  Meigs  and  Pepper,  op.  cit ,  p.  477. 


224  DISEASES    OF    CHILDEEX. 

tbe  cfficum  was  attacbed  by  a  long  mesentery.     Mr.  Hutchinson 
considered  that  the  caecum  had  been  loose  congenitally.* 

Case  2. — Mr.  Iloward  Marsbf  has  described  an  interesting  and 
successful  case  of  gastrotomj.  The  child  (a  male  infant  seven 
months  old)  was  seized,  fourteen  days  before  he  saw  him,  with 
diarrhoea,  sickness,  and  occasional  grijijing  pains  in  the  abdomen. 
The  case  was  considered  by  the  medical  attendants,  Dr.  Miller 
and  Dr.  Barnes,  of  Eye,  in  Suffolk,  to  be  due  to  catarrhal  enteritis, 
and  natural  evacuations  followed  small  doses  of  castor  oil  emul- 
sion. In  two  or  three  days  griping  and  sickness  returned,  and 
there  were  in  addition  tenesmus  and  a  quantity  of  slimy  mucus 
mixed  with  blood.  The  child  remained  in  much  the  same  condi- 
tion till  twelve  hours  before  the  consultation  (April  11th,  1875), 
when  the  pain  and  tenesmus  were  violent,  and  he  became  pale  and 
restless.  On  examination  a  firm  cylindrical  and  sausage-shaped 
tumor  was  felt  in  the  abdomen,  "  extending  from  the  umbilicus 
to  the  left  iliac  fossa,"  and  two  inches  of  the  bowel  protruded 
from  the  anus,  with  the  ileo-caecal  valve  at  the  extremity.  In- 
sufflation and  warm-water  enemata  failed  to  reduce  the  invagina- 
tion. The  child  was  placed  under  chloroform,  and  the  abdomen 
having  been  opened,  the  entering  portion  of  the  gut  was  carefully 
pulled  out,  when  it  was  found  that  the  invaginated  intestine 
"included  at  least  half  the  colon,  and  an  equal  portion  of  the 
small  intestine."  After  the  operation  small  doses  of  laudanum 
were  given,  and  the  child  drank  freely  of  milk  and  water.  The 
sickness  ceased  at  on  e  and  two  days  after  the  operation  a  fecu- 
lent motion  was  passed.  The  wound  had  nearly  healed  eighty- 
four  hours  after  the  operation,  and  a  few  days  later  the  child 
recovered.  Nine  months  after  the  child  was  in  good  health. 
This  case  is  one  which  testifies  to  the  importance  of  an  operation 
when  the  sj'mptoms  are  severe  ;  and  shows  that  the  possibility  of 
strangulation  or  inflammation  being  present,  should  not  prevent  the 
operation,  when  the  case  holds  out  no  other  hope  of  success.  In 
cases  which  appear  most  formidable  before  the  operation,  the  in- 
vagination having  been  restored,  improvement  may  at  once  set  in, 
proving  that  the  circulation  through  the  bowel  has  not  been 
interfered  with. 

*  Med.-Chir.  Trans.,  vol.  lix*,  1876,  p.  100,  Abdominal  Section  for  Intussusception 
into  Colon. 

t  Ibid.,  p.  81,  A  Cane  in  vvhicli  Abdominal  Section  was  successfully  performed  for 
Intussusception  in  an  Infant  seven  months  old. 


DISEASES   OF   THE   LIVEE.  225 

CHAPTER    XX. 

DISEASES    OF    THE   LIVER. 

Congestion  of  the  Livek:  Nature — Causes — Si/mptoms  and  treatment.  Adhesive 
Inflammation  of  the  Livek — Hepatitis — Intekstitial  Hepatitis— Hob- 
nailed Liver — Cirrhosis — Chronic  Atrophy:  Symptoms — Causes— Diagnosis 
— Morbid  anatomy— Treatment.  Syphilitic  Disease  of  the  Liver— Albu- 
minoid Enlargement. 

Congestion  of  the  liver  is  not  unfrequent  in  children.  It  is 
manifested  by  constipated  bowels  and  clay-colored  evacuations  ; 
the  appetite  is  poor,  the  complexion  sallow,  and  the  tongue  coated  ; 
the  conjunctivae  have  a  yellowish  tint,  and  the  urine  is  high- 
colored  and  turbid  on  standing.  There  is  a  sense  of  weight  and 
fulness  about  the  region  of  the  liver,  and  its  edge  may  sometimes 
be  felt  below  the  ribs  on  the  right  side.  This  is  a  state  of  active 
congestion. 

It  should  be  remarked  that  in  making  an  examination  of  the 
liver  we  shall  find  it  proportionately  larger  in  early  life  than  in 
adult  life,  and  that  what  would  be  considered  an  enlarged  area  of 
hepatic  dulness  in  the  latter  would  not  necessarily  be  so  in  the 
former. 

"  In  the  adult  the  average  weight  of  the  liver  is  one-fortieth 
that  of  the  entire  body,  whereas  previous  to  puberty  it  may  be  as 
much  as  one-thirtieth  or  even  one-twentieth."*  The  liver  varies 
in  health  as  to  size,  and  there  is  more  blood  in  it  at  one  time  than 
at  another.  "  For  instance,  the  amount  of  blood  in  the  liver  and 
its  size  are  greatly  influenced  by  diet,  both  being  temporarily 
increased  after  a  meal,  and  particularly  when  the  food  has  been 
too  large  in  quantity,  or  has  contained  an  excess  of  fatty,  sac- 
charine, or  alcoholic  ingredients. "f 

The  pathology  or  nature  of  the  change  consists  in  a  uniform 
enlargement  of  the  liver,  which  is  also  darker  in  color,  from  con- 
taining more  blood  than  it  does  normally.  The  congestion  may 
affect  chiefly  the  hepatic  or  portal  vein  ;  the  lobules  have  in  the 
first  case  a  light  border,  and  in  the  second  a  dark  border.  The 
congestion,  therefore,  is  spoken  of  as  intralobular  and  interlobular. 

The   causes   are   overfeeding   and  inattention   to   the  rules  of 

*  Lectures  on  Diseases  of  the  Liver,  by  Dr.  Murchison,  1877,  p.  7. 
t  Ibid.,  p.  131. 

15 


226  DISEASES   OF   CHILDEEX. 

health.  Rich  and  stimulating  food  in  large  quantities,  especially 
if  children  are  confined  indoors,  and  do  not  get  sufficient  exer- 
cise ;  or  cold  after  a  heavy  meal  ma}"  induce  it.  Organic  disease 
of  the  valves  of  the  heart,  as  mitral  regurgitation,  and  more  or 
less  distension  of  the  right  cavities,  will,  b}-  inducing  a  mechani- 
cal obstacle  to  the  return  of  blood  through  the  veins,  set  n^)  passive 
congestion.  Under  these  circumstances  the  liver  is  habitually 
congested,  and  it  grows  larger,  at  least  for  a  time.  "  The 
pressure  exerted  by  the  constantly  distended  hepatic  veins  causes 
atrophy  of  the  central  portions  of  the  lobules,  and  induces  a  form 
of  granular  liver,  ditferent  from  true  cirrhosis,  where  the  atrophy 
commences  at  the  circumference  of  the  lobules."*  An  enlarged 
liver  may  sometimes  occur  in  connection  with  chronic  disease  of 
the  lungs.  In  two  cases  of  emphysema  of  the  lungs,  in  children 
under  ray  care,  the  liver  was  enlarged  in  both  ;  it  may  be  present 
in  ascites,  and  sometimes  produces  it ;  it  occurs  in  mesenteric 
disease,  and  in  rickety  suljjeots,  where  the  head  is  large,  the  teeth 
decayed,  and  the  limbs  small. 

The  symptoms  are  a  dragging  pain  or  tightness  below  the  right 
ribs,  but,  as  some  children  will  bear  pressure  without  complaining, 
the  physical  signs  denoting  enlargement  of  the  liver  are  mostly  to 
be  relied  on  for  diagnosis.  In  a  large  number  of  cases  pain  is 
altogether  absent.  There  is  now  and  then  some  degree  of  jaun- 
dice present,  but  this  is  more  often  seen  in  adults  than  in  children; 
the  liver  may  be  felt  an  inch  below  the  ribs,  and  the  motions  may 
be  deficient  in  bile  when  the  skin  is  perfectly  clear.  Simple  con- 
gestion of  the  liver,  therefore,  in  children  is  not  usually  attended 
with  jaundice.  The  urine  is  scanty,  and  on  standing  ma}'-  throw 
down  copious  urates,  though  it  is  sometimes  perfectly  clear  and 
natural.  The  general  signs  are  headache,  nausea,  loss  of  appetite, 
furred  tongue,  flatulence,  and  even  vomiting.  There  may  be 
diarrhoea  and  irritation  of  the  bowels,  languor  and  drowsiness. 
The  liver  may  remain  large  after  jaundice  for  a  long  time,  and 
pain  of  a  dragging  character  ensue,  with  dyspeptic  symptoms, 
headache,  and  lassitude.  As  the  circulation  is  relieved  and  the 
turgid  capillaries  are  unloaded,  the  jaundiced  hue,  which  is  not 
necessarily  present,  passes  oft'. 

Treatment. — We  must  first  aim  at  the  removal  of  the  cause. 
When  congestion  of  the  liver  happens  to  young  children  from 

*  Lectures  on  Diseases  of  tlie  Liver,  by  Dr.  Murcliison,  1877,  p.  132. 


DISEASES    OF    THE    LIVEE.  227 

overfefeding  and  inattention  to  the  rules  of  health,  care  and  atten- 
tion to  diet  will  soon  cure  the  complaint.  In  the  shape  of  medi- 
cine a  mild  mercurial,  followed  by  a  saline  aperient,  will  excite  a 
watery  discharge  from  the  mucous  membrane  of  the  bowels,  and 
brii]g  away  some  bilious  motions.  A  warm  bath  at  bedtime  for  a 
few  nights  is  an  admirable  remedy,  and  if  there  is  pain  or  weight 
over  the  region  of  the  liver,  a  hot  poultice  will  be  beneficial.  The 
perchloride  of  mercury  with  tincture  of  bark  is  often  useful,  and 
the  nitrohydrochloric  acid  and  taraxacum  (Form.  42)  where  there 
is  debility  and  dislike  to  food.  When  the  congestion  is  due  to 
disease  of  the  thoracic  viscera  an  occasional  calomel  purge,  fol- 
lowed by  a  saline  aperient  is  equally  available,  and  the  diet  will 
require  to  be  regulated.  A  small  dose  of  calomel  stimulates  the 
upper  bowel  and  duodenum,  and  drives  the  bile  along  the'  intes- 
tines. Small  doses  of  ipecacuanha  are  also  useful  by  increasing 
the  action  of  the  liver  and  skin. 

When  children  are  sleepless  and  irritable,  bromide  of  potassium 
is  useful  if  the  liver  is  congested,  and  the  urine  high-colored  and 
scanty.  In  similar  cases,  the  chloride  of  ammonium,  w^hich  acts 
on  the  skin  and  kidneys,  is  an  excellent  remedy,  though  rather 
too  nauseous  for  children. 

Later  on,  w^hen  the  urine  is  clear,  and  there  is  debility,  the 
syrup  of  the  iodide  of  iron,  nux  vomica,  or  arsenic,  are  suitable 
remedies. 

Adhesive  Inflammation  of  the  Liver. — The  liver  may  be  enlarged 
from  interstitial  hepatitis  or  adhesive  inflammation,  and  attain  a 
large  size,  stretching  above  to  the  nipple,  and  below  to  the  navel. 
In  an  early  stage  it  has  been  known  to  extend  to  the  pubes,  and 
the  spleen  to  be  enlarged  at  the  same  time. 

In  cirrhosis  the  liver  is  at  first  increased  in  size  in  consequence 
of  an  infiltration  of  small  round  cells  into  the  areolar  tissue  of  the 
portal  canals,  and  the  increase  of  the  organ  depends  upon  the 
extent  of  the  cell  proliferation.  After  a  time,  as  this  cellular 
tissue  fibrillates  and  contracts,  the  liver  diminishes  in  size,  the 
portal  veins  are  compressed,  and  the  passage  of  blood  is  impeded  ; 
the  vascularity  of  the  liver  is  lessened,  indeed  some  of  the  branches 
of  the  portal  vein  are  entirely  obliterated,  hence  atrophy  and 
shrinking  of  portions  of  the  liver.  The  small  gall-ducts  undergo 
compression  in  the  same  way  as  the  branches  of  the  portal  vein. 
Wilks  and  Moxon  consider  that  in  many  cases  there  is  no  proof  of 


228  DISEASES    OF    CHILDREN. 

lymph  being  thrown  out  as  in  active  inflammation,  and  that  the 
whole  change  is  chronic* 

An  interesting  case  of  cirrhosis  in  a  child  is  recorded  by  Dr. 
Arthur  Fox,t  accompanied  with  jaundice,  heematemesis,  and  coma. 
After  death  the  liver  was  found  unusuall}^  large,  the  capsule  thick- 
ened, and  the  surface  finely  granular.  "  The  glands  in  the  portal 
fissure  were  much  enlarged  and  deeply  pigmented.  The  spleen 
was  enormously  gorged  with  blood  and  somewhat  friable."  The 
kidneys  were  congested  but  otherwise  normal.  The  intense  jaun- 
dice was  attributed  to  the  pressure  of  the  enlarged  glands  on  the 
bile-duct.  There  was  no  history  of  hereditary  syphilis,  but  his 
mother  had  been  a  chronic  drinker  for  years.  Dr.  Fox  considers 
that  cirrhosis  in  children  may  be  one  of  the  consequences  of  alco- 
holic heredity,  though  it  may  occur  independent  of  it  as  a  grave 
general  disease. 

Dr.  Murchison  relates  a  case  of  interstitial  hepatitis  in  a  child 
twelve  years  of  age,  coming  on  from  a  chill,  and  ending  in  cirrhotic 
contraction  and  death.  The  disease  set  in  slowly,  followed  by 
severe  abdominal  pain  and  deep  jaundice.  The  liver  extended 
nearl}^  to  the  pubes,  and  the  spleen  was  enlarged.  Death  was 
preceded  by  diarrhoea,  with  haemorrhage,  offensive  breath,  rapid 
pulse,  fever,  delirium,  irregular  breathing,  and  coma.  A  post- 
mortem examination  revealed  a  small  rounded  liver  (16  ounces\ 
the  tissue  being  firm  and  the  surface  irregular  and  puckered ; 
capsule  thickened  ;  spleen  enlarged.:}: 

Causes. — Spirit  drinking  is  the  most  common  cause  of  cirrhosis 
in  the  adult.  When  taken  up  by  the  bloodvessels  of  the  stomach, 
alcohol  is  at  once  conveyed  to  the  liver.  Murchison  relates  a  case 
in  a  boy,  nine  years  of  age,  who  drank  "a  good  deal  of  wine  and 
water  between  meals."  Paracentesis  was  twice  performed.  He 
died  from  prostration  and  collapse,  After  death  the  liver  was 
found  tough  and  hob-nailed,  and  weighed  21|  ounces. §  A  torpid 
and  sluggish  liver,  hereditary  syphilis,  cold  and  chills,  and  the 
want  of  regular  exercise  have  given  rise  to  the  disease  in  children. 

According  to  Dr.  Budd,  the  small  miliary  tubercles  found  in 

*  Pathological  Anatomy,  1875,  p.  447. 

f  "Case  of  cirriiOKis  in  a  boy  aged  eleven  years;  jaundice  of  nearly  tliree  years' 
duration."— jBnl  Med.  Journ.,  Dec.  21st,  1878,  p.  913. 

X  Lecture  on  Diseases  of  the  Liver,  by  Dr.  Murchison,  1877,  p.  632. 
^  Op.  cit.,  p.  302. 


DISEASES    OF    THE    LIVER.  229 

the  liver  of  persons  dying  of  phthisis  never  cause  adhesive  inflam- 
mation of  the  organ,  which,  as  he  sajs,  is  remarkable,  seeing  the 
tendency  they  have  to  set  up  inflammation  in  the  ditfereut  tissues 
of  the  lung." 

Diagnosis. — This  is  not  very  easy  in  children  who  exceptionally 
indulge  in  alcohol.  A  sallow  hue  of  the  skin,  or  even  jaundice; 
thirst,  dry  tongue,  furred  or  reddish  ;  scanty  and  high-colored 
urine ;  costive  bowels,  with  a  defi.ciency  of  bile  in  the  motions  ; 
pain  in  the  hepatic  region,  and  tenderness  on  pressure  are  to  be 
looked  for.  Ascites  is  often  present  to  a  considerable  degree. 
There  is  sometimes  epistaxis,  or  hfemorrhage  from  the  bowels. 

Morbid  Anatomy. — The  liver  is  much  reduced  in  size,  and  of  a 
yellowish  color,  resembling  beeswax.  Fibrous  tissue  of  a  tough 
character  is  diffused  through  the  organ  and  around  the  vessels. 
As  it  contracts,  the  parenchyma  is  squeezed  into  a  coarse  nodular 
appearance  ;  the  capsule  is  thickened  ;  the  walls  of  the  portal  vein 
are  also  thickened,  and  its  calibre  is  diminished.  The  hepatic 
cells  are  destroyed,  or  in  a  state  of  fatty  degeneration. 

Treatment. — Diet  is  important.  It  should  consist  of  milk,  eggs, 
white  fish,  farinaceous  food,  and  poultry.  At  an  early  stage,  wdien 
the  liver  is  congested  and  tender,  the  application  of  two  or  three 
leeches  may  be  necessary,  or  a  linseed  poultice  frequentl}'^  renewed. 
Small  doses  of  hyd.  c.  creta  with  rhubarb  are  serviceable,  and 
a  saline  aperient  to  unload  the  portal  circulation,  and  keep  the 
bowels  freely  open,  will  relieve  the  symptoms  greatly.  If  there  is 
loss  of  appetite  the  compound  infusion  of  gentian,  taraxacum,  and 
dilute  nitric  acid  may  be  given.  When  ascites  threatens,  diuretics, 
such  as  the  acetate  of  potash  in  decoction  of  broom,  should  be 
tried,  and  if  they  fail,  hydragogue  purgatives,  as  the  compound 
jalap  powder,  are  indicated.  When  ascites  is  present  to  a  degree 
which  embarrasses  the  respiration  and  causes  pain,  recourse  must 
be  had  to  paracentesis.  If  there  is  a  syphilitic  history,  mercury 
and  iodide  of  potassium  may  be  demanded. 

Syphilitic  diseases  of  the  liver  is  another  form  of  hepatic  enlarge- 
ment. The  lesions  of  this  organ  seen  in  hereditary  syphilis  usually 
consist  in  hardening  and  hypertrophy,  so  that  it  creaks  as  the 
knife  passes  through  it.  "On  a  uniform  yellowish  ground  a  more 
or  less  close  layer  of  small  white  opaque  grains  is  seen,  having  the 
appearance  of  grains  of  semola,  with  some  delicate  arborescences 

*  Diseases  of  the  Liver,  1852,  p.  129. 


230  DISEASES    OF    CHILDREN. 

formed  of  empty  bloodvessels.  On  pressure  no  blood  is  forced  out, 
but  only  a  slightly  yellow  serum,  which  is  derived  from  the  albu- 
men."* The  change  may  be  limited  to  the  right  or  the  left  lobe 
of  the  liver.  The  capillary  vessels  are  obliterated,  and  the  dimen- 
sions of  the  larger  vessels  reduced.  The  microscope  shows  the 
morbid  appearances  to  be  due  to  the  presence  of  a  fibro-plastic 
material.  These  changes  may  be  developed  during  intrauterine 
life.  The  symptoms  are  not  very  definite ;  there  may  be  vomit- 
ing, diarrhoea,  or  constipation,  but  never  any  jaundice.  Death 
takes  place  early.  Fatal  peritonitis,  it  has  been  said,  may  be  the 
consequence  of  the  hepatitis  being  followed  bj^  the  extension  of 
inflammation  from  the  peritoneal  covering  of  the  liver. 

There  is  a  case  recorded  by  Dr.  Goodhart,f  in  which  the  liver 
and  spleen  were  very  large  in  an  infant  two  months  old.  The  evi- 
dence of  congenital  syphilis  was  doubtful,  but  a  care  was  effected 
by  one  grain  of  gray  powder,  given  night  and  morning,  followed 
by  the  syrup  of  the  iodide  of  iron. 

Frerichs  speaks  of  three  forms  of  syphilitic  disease  of  the  liver : 
1.  Simple  interstitial  hepatitis  ;  2.  Hepatitis  gummosa  ;  3.  Waxy, 
amyloid  or  lardaceous  degeneration  of  the  liver.  All  three  forms 
may  be  found  in  the  same  liver,  or  may  exist  independently.:]: 

There  is  albuminoid  enlargement  of  the  liver,  in  which  albumin- 
ous matter  is  infiltrated  through  the  organ.  It  is  commonly  met 
with  in  rickety  children.  The  organ  is  paler,  harder,  and  more 
elastic  than  natural,  and  the  connective  tissue  around  the  portal 
vessels  is  increased.  A  similar  state  of  the  liver  is  found  in  con- 
genital syphilis.     ( Wilks  and  Moxon.) 


*  Diday  on  Infantile  Syphilis,  New  Syd.  Soc,  1859,  p.  92. 

t  Enlargement  of  the  liver  and  spleen  ;    the  hepatic  swelling  quickly  subsiding 
under  medical  treatment. — Brit.  Med.  Journ.,  vol.  ii,  1878,  p.  438. 
X  Diseases  of  the  Liver,  New  Syd.  Soc.  Trans.,  1861,  vol.  ii,  p.  152. 


ICTERUS   OR   JAUNDICE.  231 

CHAPTER  XXL 

ICTEKUS    OR    JAUNDICE. 

Definition  and  Symptoms:  Causes — Cold  and  bad  atmosphere — The  entrance  of  bile 
into  the  blood  from  distension  of  the  bile-ducts,  and  retention  of  bile  within  the  liver 
— Fecal  accumulation  pressing  on  the  liver — Treatment :  Icterus  neonatorum — • 
Acute  Yellow  Atrophy  of  the  Liver. 

By  the  term  jaundice  we  imderstatid  a  yellowish  color  of  the  in- 
tegument, caused,  bj  the  entrance  of  bile  into  the  blood ;  this, 
with  yellow  conjunctivae  and  urine,  and  the  whitish  or  pipeclay 
appearance  of  the  fseces,  distinguish  it  from  every  other  disease. 

The  sym'ptoms  of  jaundice  in  children  often  commence  with  sick- 
ness and  vomiting  of  food  ;  there  may  be  severe  frontal  headache, 
languor,  and  lassitude  ;  the  child  can  make  no  exertion  to  do  any- 
thing ;  there  is  loss  of  appetite,  and  sometimes  pain  over  the  re- 
gion of  the  liver,  though  this  may  be  absent  even  when  the  organ 
is  considerablj'  enlarged.  Pain,  indeed,  is  a  rare  symptom  in  the 
jaundice  of  children,  and  when  present  in  the  jaundice  of  adults, 
it  probably  indicates  distension  of  the  bile-ducts  from  the  passage 
of  a  gall-stone.  The  surface  of  the  body  and  conj  unctivse  generally 
assuiiie  a  yellow  appearance,  and  the  extremities  are  sometimes 
much  more  affected  than  the  back.  The  temperature  is  normal, 
and  the  pulse  slow,  except  there  is  acute  pain  over  the  liver  from 
the  amount  of  congestion  present,  and  then  there  is  dryness  of  the 
skin  and  febrile  disturbance. 

The  urine  is  generally  of  a  dark  Madeira  color,  from  the  ad- 
mixture of  bile,  and  it  stains  linen  yellow.  Casts  of  the  urinary 
tubules  have  been  observed  in  it.  In  very  severe  cases  the  sweat 
and  saliva  are  also  yellow,  and  objects  appear  yellow  to  the  eye. 
The  bowels  are  usually  constipated,  and  the  motions  pale  like  pipe- 
clay. Sometimes  there  is  diarrhoea,  and  the  stools  are  colorless,  if 
the  bile-duct  is  completely  obstructed.  In  cases  where  the  consti- 
tution is  bad,  petechise  may  appear  on  the  skin,  and  there  may 
even  be  haemorrhage  from  the  mucous  surfaces.  According  to 
Wickham  Legg,  the  tint  of  jaundice  has  been  observed  by  several 
authorities  in  the  mouth  before  it  has  been  apparent  elsewhere.* 

Causes. — Jaundice  results  in  infants  and  very  young  children 

*  St.  Bart.  Hosp.  Eept.,  vol.  xiii,  p.  12. 


232  DISEASES    OF   CHILDREN. 

from  a  bad  atmosphere  and  cold,  so  that  the  skin  and  organs  of 
respiration  do  not  perfectly  perform  their  functions.  The  disease 
is  most  common  in  the  feeble  and  delicate.  As  the  skin  takes  on 
its  proper  functions,  and  cold  is  guarded  against,  the  jaundice  dis- 
appears in  a  few  dnjs,  provided  nothing  is  given  in  the  shape  of 
food  except  breast-milk.  A  grain  of  Tlyd.  c.  Greta,  followed  by  a 
dose  of  castor  oil  or  some  other  laxative,  complete  the  treatment. 

Jaundice  may,  however,  arise  from  enlargement  and  inflamma- 
tion of  the  liver  or  umbilical  veins,  or  from  obstruction  or  inflam- 
mation of  the  bile-ducts,  or  even  absence  of  the  gall-bladder.  It 
has  been  attributed  to  spasmodic  closure  of  the  ducts,  but  whether 
this  can  produce  it  or  not,  we  know  that  the  essential  or  true 
cause  is  a  retention  of  the  Ijile  within  the  liver,  and  the  transuda- 
tion of  the  bi'e  through  the  capillaries  and  bile-ducts  into  the  cir- 
culating blood.  Jaundice  may  arise  from  congestion  of  the  liver ; 
the  secretion  of  bile  is  diminished  because  the  sorsred  state  of  the 
bloodvessels  presses  upon  the  gall-ducts,  and  does  not  allow  the 
bile  to  pass  freely  through  them.  "  In  young  persons,  and  in  per. 
sons  in  whom  the  liver  is  healthy  and  its  capsule  thin,  it  will 
necessarily  enlarge  much  more  for  a  given  force  of  distension  than 
in  persons  in  opposite  circumstances."*  The  liver  is  enlarged  and 
of  a  deep-red  color  in  the  central  parts,  whilst  the  margins  are 
pale. 

Jaundice  in  older  children,  as  in  adults,  is  most  common  in  sum- 
mer and  autumn,  and  in  some  cases  is  accompanied  with  dlarrhfjea. 
Nausea  and  sickness,  headache,  loss  of  appetite,  drowsiness,  and 
restless  nights  are  common  symptoms.  I  attended  a  severe  case  of 
jaundice  in  a  young  lad  some  years  ago,  which  came  on  after  ex- 
citement and  running  some  distance  immediately  after  a  heavy 
meal. 

Jaundice  has  arisen  from  round  Avorms  entering  the  orifice  of 
the  bile-duct  and  causing  biliary  colic,  vomiting,  and  all  the  sj'mp- 
torns  of  gall-stones  f  A  similar  case  is  also  on  record.:];  Dr.  Budd 
mentions  the  fact  that  several  cases  of  jaundice,  in  quick  succes- 
sion, have  come  to  his  knowledge  in  children  of  the  same  family, 
or  in  several  persons  living  in  the  same  locality.  He  attributes  it 
to  some  poison  (probably  miasm)  which  arrests  the  secretion  of  the 

*  Budd  on  tlie  Liver,  1852,  p.  50. 

f  Miircliison,  op.  cit.,  p.  345.  J  Brit.  Med.  Journ.,  vol.  ii,  1878,  p.  877. 


ICTEEUS   OR   JAUNDICE.  233 

liver  owing  to  some  change  in  the  blood.*  Probably  the  liver  was 
imperfectly  developed.  Some  persons  have  small  livers,  just  as 
others  have  small  hearts. 

The  diagnosis  from  cerebral  disease  consists  in  the  absence  of 
febrile  disturbance — no  heat  of  head  or  intolerance  of  light — the 
vomiting  is  less,  and  the  pulse  is  slow  rather  than  frequent.  There 
is  often  tenderness  over  the  region  of  the  liver,  the  motions  are 
pale,  and  the  urine  high-colored. 

The  treatment  of  jaundice  is  that  of  biliary  congestion.  If  there 
is  pain  or  great  tenderness  over  the  liver  a  leech  or  two  may  be 
applied  there  or  at  the  anus,  followed  by  a  warm  linseed  poultice. 
Two  grains  of  Hyd.  c.  Creta,  or  even  a  grain  of  calomel  should 
be  given  at  bedtinie  to  a  child  seven  or  eight  years  old,  followed 
by  sulphate  of  magnesia  during  the  day,  or  the  nitromuriatic  acid 
mixture,  with  taraxacum  (Form.  42).  It  is  important  to  keep  the 
bowels  open  and  to  give  a  farinaceous  diet  chiefly.  Milk  in  soda- 
water  is  nutritious  and  refreshing.  If  there  is  thirst,  barley-^vater, 
with  a  little  cream  of  tartar  in  it,  will  be  useful.  Bicarbonate  of 
soda  and  tartaric  acid  given  in  full  doses  whilst  eflfervescing  will 
relieve  sickness  and  keep  up  a  gentle  action  of  the  bowels.  If  the 
liver  remains  sluggish  and  painful,  a  lotion  of  nitric  acid  applied 
at  bedtime  under  oiled  silk  is  a  good  application.  It  causes  red- 
ness and  tingling  of  the  skin,  and  when  this  happens  it  should  be 
omitted  till  the  erythema  has  passed  away  before  it  is  reapplied. f 
Emetics  repeated  daily  are  in  favor  with  some  practitioners,  es- 
pecially when  the  jaundice  is  due  to  catarrh  of  the  bile-ducts. 

Icterus  neonatorum  is  not  a  disease  of  the  liver,  as  its  name  seems 
to  impl}^,  but  is  merely  caused  by  the  changes  in  the  color  of  the 
skin  during  the  first  few  days  of  life.  In  infants  after  birth  the 
skin  is  much  congested  ;  this  gradually  declines  till  a  rosy  tint  is 
reached  in  the  course  of  a  few  days.  It  sometimes  happens  in 
children  otherwise  well,  that  the  skin,  after  the  first  two  or  three 
days  of  life,  assumes  a  yellowish-orange  tint,  which  popularly  goes 
by  the  name  of  jaundice,  the  urine  and  motions  being  in  all  re- 
spects natural.     The  complaint  is  caused  by  the  blood  in  the  skin 

*  Diseases  of  the  Liver,  1852,  p.  273. 
f  Formula  44 : 

B:-  Acid.  nit.  dil., 5j 

Aquam  rosse  ad  .         . 5xx 

Fiat  Lotio. 


234  DISEASES   OF    CHILD  REX. 

changing  into  a  yellowisli  tint  before  tlie  normal  color  is  reached. 
The  conjunctivae  in  these  cases  remain  clear,  and  the  urine  con- 
tains no  trace  of  bile-pigment.  The  disorder  is,  therefore,  in  most 
cases,  a  mere  cutaneous  discoloration. 

This  simple  form  of  icterus  has  been  shown  to  be  frequently  due 
to  deficient  oxygenation  of  the  blood,  but  "  icterus  neonatorum  " 
may  also  represent  a  very  grave  condition,  viz.,  obstruction  of  the 
bile-duct*  from  congenital  stricture,  or  from  inspissated  bile,  or  the 
jaundice  may  have  a  py<"emic  origin  from  phlebitis  of  the  umbilical 
vein,  as  Dr.  Murchison  has  shown  (op.  cit.,  p.  347). 

A  male  infant,  seven  weeks'  old,  was  sent  to  me  by  Mr.  Butler, 
of  Guildford,  on  April  8th,  1879,  suftering  from  severe  jaundice. 
On  the  third  day  after  birth,  he  became  very  yellow,  but  took 
Swiss  milk  well,  and  was  also  suckled  by  a  wet-nurse.  The  child 
was  well  nourished,  and  had  not  wasted,  though  the  mother  said 
he  seemed  less  plump  than  at  birth.  The  color  of  the  integument 
was  of  a  deep  yellow  on  the  face  and  thorax,  and  of  a  lighter  hue 
below  the  nmbilicus,  scrotum,  and  buttocks.  The  conjunctivae 
presented  a  yellowish-green  tint,  varying  from  time  to  time  in 
intensity.  Both  the  liver  and  spleen  were  enlarged.  There  was  a 
good  deal  of  tympanites,  but  the  child  could  retain  his  food  ;  there 
was  no  vomiting,  the  faeces  were  relaxed,  and  although  nearly 
always  clay  colored,  a  trace  of  bile  had  been  seen  in  the  motions ; 
the  urine  was  of  a  pale-saffron  color.  The  history  of  the  case 
favored  the  supposition  that  the  jaundice  might  be  caused  by 
absence,  obstruction,  or  malformation  of  the  gall-bladder  or  bile- 
ducts.  He  was  ordered  to  be  fed  on  milk  and  lime-water,  and  as 
the  diagnosis  could  at  best  be  only  doubtful,  a  powder  containing 
a  grain  of  Hydr.  cum  Greta  and  bicarbonate  of  soda,  was  ordered, 
occasionally  at  bedtime,  and  a  mixture  containing  the  solution  of 
carbonate  of  magnesia  and  taraxacum  during  the  day. 

Mr.  Butler  informed  me,  six  months  later,  that  the  child  had 
died,  and  a  post-mortem  examination  had  been  made  by  Mr. 
Bisshopp,  of  Tunbridge  Wells,  on  August  23d,  1879.     A  good  deal 

*  Mr.  Glaister  has  described  a  most  interesting  case  of  fatal  ^'icterus  neowitorum," 
■where  the  common  bile-duct  was  found  to  be  constricted,  "  a  few  lines  from  its  duodenal 
insertion,"  and  the  left  hepatic  duct  "seemed  to  split  up  into  fibrous  threads."  The 
mother  had  borne  seven  cliildren  before,  six  of  whom  had  sliown  similar  symptoms, 
four  out  of  tliese  six  cases  ending  fatally.  Both  parents  were  troubled  with  frequent 
liepatic  symptoms. — Lancet,  vol.  i,  1879,  pp.  293,  330. 


ICTERUS    OR    JAUNDICE.  -  235 

of  ascitic  fluid  was  found  in  the  abdominal  cavity  of  a  deep-yellow 
color,  wliicli  appeared  due,  not  to  any  inflammation  of  the  peri- 
toneum itself,  but  to  the  dense,  hard,  contracted  state  of  the  liver, 
from  chronic  inflammatory  changes,  which  had  obstructed  the 
hepatic  circulation  precisely  in  the  manner  seen  in  cirrhosis.  The 
gall-bladder  contained  a  glairy  white  fluid,  but  no  bile.  The 
hepatic,  cystic,  and  common  bile-ducts  were  all  absent.  The  ana- 
tomical malformation  had  caused  the  incurable  jaundice,  the 
chronic  inflammation  of  the  liver  and  dropsy,  and  finally  the 
general  wasting  and  death. 

Acute  yellow  atrophy  of  the  liver  {suppressed  secretion  of  bile — 
fatal  Jaundice)  has  been  met  with  in  3'oung  subjects,  but  it  is  very 
rare  in  children.  "Out  of  25,700  cases  admitted  into  the  London 
Fever  Hospital  in  nine  years,  there  was  only  one  case  of  this 
disease."*  It  is  supposed  to  consist  in  inflammation  of  the  organ, 
which  leads  to  suppression  of  bile,  and  degeneration  of  structure. 
In  this  curious  disease  the  liver  quickly  undergoes  degeneration, 
after  a  few  daj's  of  indisposition,  and  hepatic  derangement.  The 
premonitory  symptoms  are  nausea,  furred  tongue,  diarrha3a,  or 
constipation,  slight  pyrexia ;  there  may  be  rheumatic  pains  and 
cardiac  distress.  Jaundice  is  alwaj- s  present,  but  bile  is  to  be  seen 
in  the  stools,  and  there  is  no  obstruction  in  the  bile-ducts.  The 
severe  symptoms  are  owing  to  biliary  suppression,  and  the  accu- 
mulation of  bile  products  in  the  blood.  The  skin  becomes  hot  and 
dry,  the  pulse  quick,  vomiting  of  cofltee-grounds  matters  follows, 
with  haemorrhage  from  the  bowels.  Sometimes  there  is  epistaxis, 
and  the  bowels  are  constipated ;  the  urine  is  of  a  dark-brown 
color,  like  porter,  and  contains  bile,  tyrosin,  leucin,  etc.  As  the 
disease  proceeds,  delirium  and  coma  (sometimes  convulsions)  come 
on,  the  motions  are  dark  from  the  presence  of  blood,  the  skin  is 
of  a  deeper  jaundice  hue,  and  petechial  spots  of  ecchymosis  occur 
in  diflerent  parts  of  the  body. 

In  the  case  of  a  boy,  aged  seventeen,  described  by  the  late  Mr. 
Harry  Leach,  there  had  been  "  slight  icterus  for  fourteen  days, 
pain  across  the  epigastrium,  anorexia,  and  frequent  vomiting." 
These  symptoms  were  followed  by  stupor,  debility,  intense  jaundice, 
pain  over  the  liver,  which  was  enlarged,  cofi:ee-grounds  vomiting, 
convulsions,  frantic  delirium,  loud  screaming,  and  death.  The 
pulse  was  weak  and  irregular,  the  respiration  slow,  the  heart 

*  Murchison,  op.  cit.,  p.  257. 


236  DISEASES    OF    CHILDEEX. 

thumping.  The  ho\yel5  were  constipated,  the  urine  (which  was 
of  the  color  of  porter/  required  to  be  drawn  off  with  a  catheter.  It 
contained  tyrosin,  a  Large  quautitj'  of  urea,  phosphates,  and  chlo- 
rides, but  no  albumen.  The  sp.  gr.  was  1035.  A  post-mortem 
examination  revealed  congestion  of  both  lungs  ;  the  spleen  weighed 
4f  oz.,  both  kidneys  lOi^  oz.,  and  were  granular  and  fatty;  the 
liver  weighed  31|  oz. — it  was  soft,  pale,  and  Habby  ;  the  inferior 
aspect  was  of  a  dark-greenish  hue  from  the  accumulation  of  bile 
in  the  independent  portions.  The  biliary  vesicle  and  ducts  were 
empty  and  shrunken.     The  portal  vein  was  free.* 

This  form  of  jaundice,  ending  in  coma,  occurred  to  four  mem- 
bers of  the  same  family ;  in  the  case  of  two  of  them,  being 
brothers  of  the  respective  ages  of  11  and  13  years,  it  terminated 
fatally.f 

Causes. — Syphilis,  and  irregular  habits  in  youth,  predispose  to 
the  disease.  According  to  Freriehs,  hypersemia  and  diffuse  in- 
flammation of  the  liver  are  excitino;  causes. 

Diagnosis. — The  disease  resembles  yellow  fever,  but  is  to  be 
distinguished  from  it  by  the  shrinking  of  the  liver,  and  the  pres- 
ence of  leucin  in  the  urine. 

Morbid  Anatomy. — -The  liver  is  shrunk  and  shrivelled,  and  the 
division  into  lobules  is  not  discernible ;  it  may  shrink  to  one-half 
its  size  in  the  course  of  a  week  or  ten  days,  "  it  is  soft  and  flabby, 
and  of  a  light-yellow  color,  or  brownish-yellow,  or  crimson  orange, 
or  some  kindred  tint.";}; 

It  may  be  enlarged  at  an  early  stage,  but  this  is  of  short  dura- 
tion, and  is  soon  followed  by  a  dimii;ution  in  its  bulk.  The 
hepatic  cells  disappear,  leaving  only  granular  matter  and  oil,  the 
biliarj^  ducts  are  pervious,  the  gall-bladder  is  empty,  the  spleen  is 
congested  and  enlarged. 

Treatment. — This  is  almost  hopeless.  At  an  early  stage  cupping 
or  leeching  over  the  liver  may  be  of  service ;  an  emetic,  followed 
by  a  full  dose  of  calomel,  appear  to  be  the  remedies  which  in  a  few 
cases  have  been  attended  by  recovery.  Dr.  Budd  reconmicnds 
sulphate  and  carbonate  of  magnesia,  with  small  doses  of  sal 
volatile. 

*  Brit.  Med.  Jour.,  1878,  vol.  ii,  p.  877. 
t  Budd,  op.  cit.,  p.  2G9. 
X  Ibid.,  p.  270. 


PAINLESS   ENLAllGEMENTS   OF   THE   LIVER.  237 

CHAPTER    XXII. 

PAINLESS    ENLARGEMENTS    OF    THE    LIVER. 

Hydatids  of  the  Liver  :  Pathology — Symptoms — Causes — Diagnosis — Termination 
and  Treatment.  Lardaceoub  ok.  Amyloid  Disease.  Fatty  Livek.  Simple 
Hypertkophy'  of  Liver. 

Hydatid  tumors  of  the  liver,  most  common  during  the  middle 
period  of  life,  are  rarely  found  in  childhood  or  old  age.  I  have 
seen  a  large  hydatid  cyst  extending  downwards  to  the  umbilicus, 
and  across  to  the  splenic  region,  in  a  girl  eight  years  of  age ;  and 
cases  are  recorded  of  its  occurrence  in  children  considerably  younger. 
A  membranous  sac  or  cyst  forms  in  the  liver,  containing  a  color- 
'less  limpid  fluid  like  water.  In  the  fluid  a  variable  number  of 
cysts  or  bladders  facephalocysts)  are  found,  varying  in  size  "from 
a  millet-seed  to  a  goose's  egg."  Hundreds  or  even  thousands  of 
these  acephalocysts  may  be  detected  in  a  single  parent  cyst,  to  the 
walls  of  which  the  scolices  of  the  echinococcus  adhere.  The  sac  or 
cyst  is  formed  by  the  tissue  of  the  liver,  and  is  of  variable  thick- 
ness, being  thicker  in  tumors  of  old  than  of  recent  standing. 

Hydatid  tumors  grow  very  slowly,  and  are  generally  painless, 
at  least  when  of  small  size,  and  they  are  rarely  accompanied  by 
dropsy  or  jaundice.  This  latter  symptom  will  depend  upon  whether 
the  common  bile-duct  undergoes  compression  from  being  sur- 
rounded by  enlarged  lymphatic  glands,  or  is  otherwise  obstructed 
by  some  swelling  of  the  liver,  when  there  may  be  continued  or 
remittent  jaundice.*  A  case  is  also  recorded  by  Dr.  Gayley,  in 
Avhich  a  patient  had  repeated  attacks  of  hepatic  pain  with  jaun- 
dice. The  hydatids  came  away  per  anum,  and  the  health  remained 
good.f  Hydatid  tumors  may  be  large  enough  to  fill  the  greater 
part  of  the  abdominal  cavity,  or  to  reach  upwards  into  the  chest 
nearly  to  the  clavicle  ;  they  may  not  exceed  the  size  of  an  orange, 
and  when  deeply  seated  they  may  escape  observation  altogether.^ 

When  they  can  be  felt  they  are  perfectly  smooth,  and  they  have 
an  elastic  or  fluctuating  feel.  Occasionally  the  so-called  hydatid 
fremitus  may  be  felt.  If  several  cysts  exist,  the  surface  of  the 
liver  may  be  irregular  or  lobulated. 

*  Path.  Trans.,  vol.  xxv,  p.  156.  f  Path.  Soc,  Oct.  20th,  1874.. 

X  Diseases  of  the  Liver,  by  C.  Murchison,  M.D.,  1877,  p.  55. 


238  DISEASES    OF    CHILDEEX. 

Ascites  is  au  occasional  consequence  of  pressure  and  interfer- 
ence with  the  circulation  through  the  liver,  but  a  case  is  on  record 
where  the  portal  fissure  was  much  pressed  upon  without  producing 
this  result.*  In  some  cases  there  is  oedema  of  the  lower  limbs 
from  pressure  on  the  vena  cava,  and  albumen  has  been  detected 
in  the  urine  from  the  tumor  compressing  the  renal  vein.  In  very 
exceptional  instances,  secondary  hydatid  cysts  have  been  found  in 
the  spleen  and  kidnej-. 

Causes. — The  adult  tssnia  ecchinococcus  inhabits  the  intestines 
of  the  dog ;  the  ova  are  voided  in  the  fseces  of  the  animal,  and 
being  swallowed  with  the  food  and  drink,  find  their  way  to  the 
liver,  lung,  or  some  other  organ,  and  there  become  encysted. 

Diagnosis. — When  a  tumor  occupying  the  region  of  the  liver 
is  smooth  and  globular,  and  there  is  fluctuation  with  an  absence 
of  pain,  fever,  and  jaundice,  and  the  general  health  moreover 
remains  good,  we  should  .suspect  the  existence  of  echinococci. 
The  possibility  of  abscess  or  ovarian  cyst,  and  especially  pleuritic 
effusion,  should  be  remembered,  but  these  conditions  could  scarcely 
be  confounded  with  a  hydatid  C3'st,if  care  be  taken  before  coming 
to  a  conclusion. 

Termination. — The  contents  of  a  hydatid  tumor  maj'  ultimately 
dry  up,  and  the  sac  become  obliterated,  or  it  may  burst  spontane- 
ously through  the  walls  of  the  abdomen,  or  into  the  bronchi, 
intestine,  or  stomach,  and  the  patient  recover.  The  cyst  may 
suppurate  and  induce  pyasmia  and  gangrenous  abscess  of  the 
liver,  or  it  may  burst  into  the  pleura  and  produce  fatal  empyema. f 
When  it  bursts  into  the  lung,  the  patient  spits  up  a  hydatid  from 
time  to  time,  and  as  the  disease  proceeds  and  the  orifice  in  the 
pulmonary  tissue  becomes  larger,  several  hydatids  may  be  coughed 
up  at  one  time.  The  symptoms  attending  this  pulmonarj'  com- 
plication are  frequent  straining  cough,  constant  expectoration  of 
a  sanguineous  or  purulent  character,  and  a  disgusting  taste  in  the 
mouth  from  the  admixture  of  bile.|  The  most  dangerous  conse- 
quence is  the  liability  of  the  sac  under  gradual  growth  and  dis- 
tension to  ulcerate  and  rupture  into  the  peritoneum,  and  there  set 
up  fatal  inflammation.  The  tumor,  too,  may  continue  to  increase 
in  size,  causing  such   compression  of  the  hepatic  structure,  and 

*  Clin.  Trans.,  1878,  p.  236. 

t  Miirchison,  op.  cit.,  p.  120-123. 

t  Budd,  op.  cit.,  p.  4-44. 


PAI^•LESS    ENLARGEMENTS    OF   THE    LIVER.  239 

disturbing  the  functions  of  adjacent  organs  by  its  growth,  till  it 
wears  the  child  out  by  pain  and  exhaustion. 

Treatment. — Up  to  the  present  time,  drugs  have  proved  useless. 
"When  the  tumor  is  large,  it  should  be  tapped  with  a  fine  explora- 
tory trocar,  or  aspirator,  and  the  fluid  drawn  off.  The  with- 
drawal of  a  small  quantity  of  fluid  by  the  hypodermic  syringe,  as 
a  means  of  diagnosis,  has  been  sometimes  followed  by  complete 
atro})hy  of  the  cyst.  The  cases  most  likely  to  end  in  cure  are 
those  which  have  a  thin  cyst-wall,  and  where  the  vesicles  are  few 
in  nundjer,  or  the  acephalocyst  is  solitary.  Several  successful 
cases  are  related  by  Budd,*  and  Dr.  Murchisonf  gives  a  table  of 
eighty  cases  in  which  a  cure  followed  the  operation  of  puncture. 
Moreover,  inflammation  and  suppuration  may  be  set  up  iu  the 
sac  by  puncture,  and  recovery  even  then  may  ensue  ;  or  the  hyda- 
tid may  slowly  exhaust  the  patient's  strength,  as  we  sometimes 
see  in  opening  a  large  chronic  abscess.  Even  the  simple  process 
of  puncture  is  not  free  from  danger,  as  there  is  a  risk  of  the  irri- 
tating fluid  escaping  into  the  abdominal  cavity  and  provoking 
inflammation.  Several  fatal  cases  are  recorded  from  puncture, 
death  occurring  in  a  few  hours,  faintness,  rigors,  vomiting  of 
bilious  matter,  pain  in  the  abdomen,  and  coldness  of  the  extremi- 
ties preceding  death.  Sometimes  peritonitis  has  ensued,  followed 
by  a  slow  recover3^:{:  A  case  is  related  by  Mr.  Bryant,  where 
agonizing  pain,  lividity,  unconsciousness,  and  sudden  death  fol- 
lowed the  tapping  of  a  hydatid  cyst,  and  the  result  of  the  post- 
mortem examination  seemed  to  show  that  the  portal  vein  had 
been  transfixed  by  the  trocar,  and  that  the  hydatid  fluid,  being 
sucked  into  it,  acted  as  a  fatal  poison.^ 

Injections  into  the  cyst  have  been  tried,  those  containing  iodine 
or  carbolic  acid  being  generally  selected.  Iodide  of  potassium 
given  internally,  and  iodine  ointment  rubbed  in  over  the  enlarged 
liver,  have  severally  been  employed  without  success. 

Lardaceous  or  amyloid  disease  of  the  liver — scrofidous  enlargement 
of  the  liver  (Budd) — is  a  disease  which  belongs  to  the  weak  and 
cachectic.  In  this  peculiar  degeneration  of  the  liver,  waxy  and 
fatty  matter  is  infiltrated  throughout  it,  and  in  many  instances  a 

*  Budd,  op.  cit.,  p.  448. 

t  Miirchison,  Clinical  Lectures  on  Diseases  of  the  Liver,  1877,  p.  77. 

X  Frericlis  on  Diseases  of  the  Liver,  New  Syd.  See,  vol.  ii,  p.  251. 

?  Clin.  Trans.,  1878,  p.  236. 


240  DISEASES   OF    CHILDREN". 

similar  extension  of  the  disorder  can  be  traced  into  the  different 
tissues,  as  the  lymphatic  glands,  bloodvessels,  spleen,  and  renal 
organs. 

Pathology. — The  liver  is  greatly  enlarged  and  thickened  ;  it  may 
be  some\vhat  paler  than  usual  from  a  deficiency  of  blood,  or  at 
other  times  scarcely  altered  from  its  normal  appearance.  In  some 
cases  it  presents  a  white  appearance  on  section,  and  the  lobules 
are  either  obliterated  altogether,  or  they  are  scarcely  to  be  dis- 
tinguished. This  "  waxy  "  or  albuminous  matter  never  becomes 
hard,  or  shows  any  tendency  to  contract  like  lymph,  which  is  the 
product  of  inflammation ;  it  is  destitute  of  cells  or  organization. 
The  surface  of  the  liver  is  smooth,  wliite  and  glistening,  even 
when  the  disease  is  of  long  standing.  "  These  circumstances," 
saj'S  Dr.  Budd,*  "  explain  the  fact  that  the  foreign  matter,  though 
large  in  araou'ut,  does  not  much  impede  either  the  passage  of  the 
blood  through  the  liver  or  the  escape  of  the  bile  through  the 
ducts."  The  lobules  become  of  a  faint  reddish  color  and  enlarged, 
the  gland  structure  is  uniform  and  smooth,  and  on  section  resembles 
"  smoked  salmon."  This  peculiar  deposit  may  occur  in  isolated 
portions  of  the  liver,  or  it  may  be  scattered  throughout  the  entire 
organ.  It  is  first  deposited  within  the  lobules,  and  between  the 
secreting  cells,  which  are  diminished  in  number.  A  similar  con- 
dition of  the  spleen  often  accompanies  this  degeneration.  Micro- 
scopically oil-globules  can  be  seen  in  abundance  when  the  fatty 
matter  is  examined,  but  the  great  increase  in  the  size  of  the  liver 
is  owing  to  the  infiltration  of  this  peculiar  morbid  matter  stretching 
the  capsule  and  obliterating  the  appearance  of  the  lobules.  "It 
first  atifects  the  minute  vessels,  especially  the  arteries,  and  extends 
to  the  capillaries,  afterwards  invading  the  proper  elements  of  the 
texture  implicated. "f  Syphilis  and  scrofulous  disease  of  the 
bones,  especially  when  accompanied  by  chronic  suppuration,  are 
its  usual  casual  relations.  Caries  of  long  standing  appears  to  be 
a  common  cause.  "  Out  of  eighty-three  cases  of  lardaceous  dis- 
ease, seventy-three  were  in  connection  with  either  suppuration 
or  syphilis,  leaving  bat  ten  cases  which  were  not  ostensibly 
accounted  for  by  these  agents.":]; 

The  general  symptoms  are  those  indicative  of  anaemia,  gradual 


*  Diseases  of  Liver,  1852,  p.  318. 

t  Pathological  Anatomy,  by  Wilks  and  Moxon,  1875,  p.  640. 

%  Discussion  on  Lardaceous  Disease,  Path.  Soc.,  March  18ih,  1879. 


PAINLESS    ENLARGEMENTS    OF    THE    LlVEr..  241 

wasting  and  cachexia.  It  comes  on  so  slowly  that  if  it  were  not 
for  the  increased  size  of  the  abdomen,  no  notice  would  Ije  taken 
of  it ;  there  is  occasional  yellowishness  of  the  conjunctiva  and  a 
little  tenderness  over  the  liver.  After  a  time  there  is  languor 
and  loss  of  appetite,  gastro-intestinal  derangement,  and  sometimes 
vomiting  and  diarrhoea,  with  pale  stools.  Fever  of  an  irregular 
type  is  common,  attended  with  cough,  dyspnoea,  and  quick  pulse; 
the  urine  is  often  of  low  specific  gravity  from  the  presence  of 
albumen,  which  is  a  consequence  of  the  kidnej'S  ]iartici[)ating  in 
the  waxy  degeneration,  and  the  drain  of  albumen  may  be  so  great 
as  to  destroy  life.  The  presence  of  waxy  casts  in  the  urine  is  a 
guide  to  diagnosis. 

In  addition  to  these  symptoms  we  frequently  meet  with  enlarge- 
ment of  the  submaxillary  and  cervical  glands.  The  disease  may 
terminate  in  peritonitis,  pneumonia,  or  tubercular  disease  of  the 
lungs ;  but  more  frequently  it  ends  in  exhaustion,  ascites,  or  general 
anasarca. 

In  a  case  mentioned  by  Portal  of  a  boy,  aged  8,  who  died  from 
the  disease,  the  bronchial  and  mesenteric  glands  were  found 
enlarged,  "  and  filled  with  a  substance  like  plaster,"  and  a  slice  of 
the  liver  exposed  to  heat  became  hardened  like  albumen*  In 
another  case,  related  by  Abercrombie,  of  a  boy,  aged  11  years, 
there  was  found  after  death,  extensive  disease  of  the  mesenteric 
glands,  the  lungs  were  tuberculous,  and  there  was  a  chain  of 
enlarged  glands  extending  from  the  bifurcation  of  the  trachea  to 
the  diaphragm  ;  some  contained  pus,  others  were  of  cartilaginous 
hardness,  whilst  in  some  there  were  calcareous  particles.f 

There  is  little  to  be  hoped  from  treatment  beyond  attention  to 
the  general  health,  warm  clothing,  nourishing  diet,  chloride  of 
ammonium,  preparations  of  iron,  cod-liver  oil,  and  pure  air. 
"When  there  is  disease  of  the  joints  the  surgeon's  aid  may  be 
required,  and  if  the  complaint  has  a  syphilitic  origin,  it  will 
demand  special  remedies.  Dr.  Budd  gives  as  his  experience  that 
he  has  met  with  more  than  one  instance  where  recovery  took 
place,  the  peculiar  morbid  matter  passing  oft*  with  the  bile,  or 
becoming  absorbed. 

Fatty  Liver. — This  form  of  enlarged  liver  arises  from  the  accumu- 
lation of  oil  within  its  substance.     The  organ  increases  uniformly 

*  Budd  on  the  Liver,  1852,  p.  304.  f  Ibid.,  p.  305. 

16 


242  DISEASES   OF   CHILDREN. 

in  size  in  every  direction ;  it  is  smootli  on  its  surface,  of  doughy 
consistence,  and  on  examination,  after  deatli,  it  is  found  to  be 
pale  in  color.  No  matter  how  severe  the  disease  may  be,  the 
secretion  of  bile  is  not  interfered  with,  therefore  jaundice,  in 
uncomplicated  cases,  does  not  occur ;  the  superficial  veins  of  the 
abdomen  ave  not  enlarged,  and  there  is  no  ascites. 

Symptoms. — These  are  ansemia  and  debility,  languor,  lassitude, 
flatulence,  irregular  bowels,  and  depression  of  spirits.  The  skin  is 
bloodless,  and  has  a  sallow  or  waxy  appearance,  resembling  fine 
polished  ivory,  or  a  common  wax  model.  Most  of  the  constitu- 
tional symptoms  are  "  often  due  for  the  most  part  to  fatty  degener- 
ation of  other  organs,  and  more  especially  of  the  heart."* 

The  spleen  is  rarely  enlarged,  and  the  complaint  appears  to 
arise  chiefly  in  connection  with  phthisis,  or  some  other  wasting 
disorder. 

Treatment. — This  consists  in  attention  to  the  digestive  organs 
by  alkalies,  vegetable  bitters,  and  aperients.  The  waters  of  Ems, 
Vichy,  and  Schwalbach  are  to  be  recommended.  AVhen  an?emia  is 
the  leading  feature,  the  preparations  of  iron,  especially  the  ferri  et 
ammonite  citras  will  be  found  serviceable.  The  treatment,  how- 
ever, resolves  itself  into  that  which  the  primary  aftection  requires. 

A  simple  hypertrophy  of  the  liver  has  occasionally  been  met  with 
in  diabetes. 


CHAPTER  XXIII. 

DISEASES    OP    THE    SPLEEN. 

Symptoms:  Pain  in  left  hypochondrium — Cough — Dyspnoea — Salloumess  of  complexion — 
Increased  size  of  the  abdomen — May  lead  to  cirrhosis  and  enlarged  superficial  veins  over 
abdomen.  Pathology — Causes:  Ague — Typhoid  fever — Diseases  of  liver — 06- 
structive  disease  of  the  heart — Emphysema  of  the  lungs — Tuberctdosis — Syphilis — Ance- 
mia.  Diagnosis:  Oenerally  easy  on  account  of  thinness  of  abdominal  walls — Not  to 
be  mistaken  for  enlarged  liver,  kidney,  or  mesenteric  glands.  Treatment;  Attention 
to  the  general  health — Fomentations — Poultices  and  leeches  in  the  acute  stage — Mild 
mercurials  in  syphilitic  cases — Quinine  and  arsenic  if  traceable  to  ague — Chalybeates  in 
anaemia. 

Affections  of  the  spleen  in  children  have  been  in  my  own  per- 
sonal experience  almost  exclusively  confined  to  the  lower  classes, 
and  even  among  them  they  are  not  of  frequent  occurrence. f     "  We 

^"  Dise.xses  of  the  Liver,  by  C.  Miirchison,  M.D.,  1877,  p.  49. 

t  "  00  cases  of  deatli  returned  as  due  to  spleen  diseases  in  England,  among  male  sub- 
jects, wliicii  occurred  in  1877,  only  9  were  under  five  years  of  age  ;  and  of  07  females, 


DISEASES    OF   THE   SPLEEN.  243 

sometimes  meet  with  splenic  disease  in  children  in  this  country, 
and  more  especially  in  dispensarj^  and  hospital  practice,  where  poor 
and  insufficient  food,  bad  ventilation,  and  humid  houses  have  ex- 
erted a  predisposing  eifect."*  They  may  be  described  as  those  of 
enlargement  and  hj^'pertrophy,  arising  chiefly  from  congestion  and 
inflammation. 

The  elastic  structure  of  the  spleen  renders  it  susceptible  of  dis- 
tension from  slight  causes,  and  hence  any  afl:ection  of  the  liver  or 
arrested  skin  action  may  increase  its  bulk.  If  these  disorders  con- 
tinue, the  spleen  fails  after  a  time  to  propel  the  blood  onward, 
and,  from  such  arrest,  permanent  congestion  and  enlargement  fol- 
low ;  and  sometimes  inflammation  and  abscess. 

There  is  no  organ  so  variable  in  size  and  consistence  as  the 
spleen.  "It  is  much  smaller  in  elderly  than  in  young  people — 
indeed,  it  may  waste  away  in  old  age  to  a  pale  relic  of  not  more 
than  two  or  three  drachms  in  weight. "f 

In  amyloid  or  lardaceous  degeneration,  the  Malpighian  cor- 
puscles may  alone  be  afiected.  The  spleen  is  enlarged,  and  its 
density  is  increased.  On  section,  clear  waxlike  little  bodies,  of 
variable  size,  having  the  appearance  of  boiled  sago,  are  to  be  seen 
in  the.-e  corpuscles,  hence  the  disease  is  known  as  the  "  sago  spleen," 
which  is  frequently  seen  in  those  children  who  die  of  phthisis. 
There  is  another  variety  of  the  amyloid  spleen  in  which  the  pulp 
is  chiefly  involved.  It  appears  to  be  an  advanced  condition  of  the 
former  afiection,  the  disease  extending  from  the  corpuscles  to  the 
pulpy  parenchyma.:}: 

The  general  symptoms  are  not  well  marked,  but  if  the  spleen 
has  attained  any  considerable  size,  there  is  usually  some  amount 
of  pain  or  tenderness,  or  distension  in  the  left  hypochondriac 
region,  or  over  the  epigastrium,  extending  through  to  the  back; 
and  there  may  be  cough  or  dyspnoea  on  lying  down ;  but  these 
are  only  occasional  symptoms.  The  child  is  sallow  and  pale  ;  the 
tongue  is  bloodless  and  clean ;  the  pulse  is  weak  and  frequent,  and 

only  12  were  under  five  years  of  age.  Under  fifteen  years  of  age  it  is  extremely  rare. 
In  London,  in  the  year  1877,  of  8  cases  of  death  in  males,  3  were  under  five  years  of 
age  ;  and  of  10  cases  of  females,  2  were  under  five  years  of  age." — Fortieth  Annual  Re- 
port of  the  Registrar-Oeneral,  pp.  152-158. 

*  Reynolds's  System  of  Medidine,  vol.  v,  p.  178,  article.  Diseases  of  the  Spleen,  by 
J.  E.  Warden,  M.D.,  F.R.C.P. 

t  Pathological  Anatomy,  by  Wilks  and  Moxon,  1875,  p.  473. 

X  Pathology  and  Morbid  Anatomy,  by  T.  H.  Green,  M.D.,  1871,  p.  69. 


244  DISEASES    OF   CHILDREN. 

tliere  is  loss  of  flesh  and  strengtli.  The  nrine  often  contains  urates, 
and  the  motions  are  offensive,  deficient  in  bile,  or  they  are  loose 
and  contain  mucus.  Sometimes  they  are  constipated.  In  some 
cases  there  is  scarcelj^  any  inconvenience  bej'ond  that  caused  by  the 
increased  size  of  the  abdomen  from  the  splenic  tumor,  the  appetite 
and  digestion  being  excellent.  In  two  cases  that  came  under  my 
notice,  although  the  tumor  reached  below  the  umbilicus  in  one 
case,  and  nearly  filled  the  abdomen  in  the  other,  there  were  no 
noticeable  symptoms  beyond  the  inconvenience  of  a  bulky  mass  in 
the  abdomen.  The  complexion  was  sallow  in  both  cases,  but  there 
was  no  headache,  no  fever,  no  pain  in  the  side,  or  shoulder,  which 
is  often  mentioned  by  writers.*  In  other  instances  pain  is  com- 
plained of  on  pressure  over  the  splenic  region  ;  the  child  lies  on 
the  left  side  with  its  knees  drawn  up,  and  is  restless  and  sleepless 
at  night.  As  splenic  disease  progresses,  and  the  blood  becomes 
more  impoverished,  an  anaemic  bruit  may  be  heard  over  the  base 
of  the  heart.  There  may  be  swelling  of  the  abdomen  terminating 
in  ascites  ;  but  this  is  very  rare,  owing  to  the  thick  capsule  of  the 
spleen  not  admitting  of  the  exudation  of  any  fluid,  as  happens  in 
some  affections  of  the  liver  and  intestines.  The  spleen,  being  out 
of  the  way  of  the  portal  circulation,  has  no  direct  tendency  to 
cause  ascites ;  but  when  there  is  cirrhosis,  or  any  mechanical  im- 
pediment to  the  venous  circulation  in  the  liver,  the  spleen  may 
become  enlarged.  When  the  spleen  has  attained  a  very  large  size, 
the  superficial  veins  become  distended,  in  consequence  of  an  inter- 
ference with  the  circulation  through  the  deeper  abdominal  vessels. 
In  very  long-standing  cases  of  splenic  disease,  the  patient  becomes 
anaemic,  from  a  deficiency  of  red  corpuscles  in  the  blood,  and  an 
excess  of  the  white.  In  one  disease  of  the  spleen  there  is  an  excess 
of  white  corpuscles  in  the  blood  (leukpemia)  over  the  red,  just  as 
there  is  in  disease  of  the  lymphatic  glands,  and  there  is  associated 
with  it  at  the  same  time  a  new  growth  of  lymphatic  tissue  in  the 
spleen.     Hence  the  tendency  to  pallor,  to  03dema  of  the  limbs,  to 

*  "  The  shoulder-tip  pain  and  the  nerve  tenderness  in  these  diseases  are  owing,  as 
I  believe  they  are  in  liver  diseases,  to  an  extension  of  irritation  or  inflammation  from 
the  diseased  organ  along  its  pneumogastric  twigs  to  the  trunk  of  the  par  vagiira.  In  a 
case  in  which  the  morbid  state  of  the  spleen  has  been  intense,  and  continued  for  a  time, 
this  irritation  or  inflammation  passes  up  the  trunk  of  the  nerve  to  the  base,  and  even 
to  the  origin  of  the  par  vagum,  and  tiie  two  divisions  of  the  spinal  accessory,  giving 
rise  to  pains  tliere,  and  other  distin-bances." — On  the  Symmetry  of  the  Pancreas  and 
Spleen,  by  D.  Emljleton,  M.D.,  Brit.  Med.  Journ.,  vol.  ii,  1874,  p.  371. 


DISEASES    OF   THE   SPLEEX.  245 

haemorrhage  from  the  gums  or  nasal  passages,  as  the  consequence 
of  these  changes  in  the  circulatino-  blood.  Under  a  continuance  of 
these  symptoms  the  child  sinks  from  exhaustion,  or  death  is  often 
due  to  diarrhoea. 

Pathology, — As  we  are  unacquainted  with  the  functions  of  the 
spleen,  we  are  in  doubt  concerning  the  theory  of  the  morbid 
changes  to  which  it  is  liable.  Its  turgidity,  probably,  depends 
upon  some  relaxation  of  the  vessels  and  tissues  of  which  it  is  com- 
posed, as  well  as  to  a  nerve  paresis.  The  fact  of  the  spleen  having 
been  removed  from  the  body  without  impairing  the  rest  of  the 
functions  would  go  far  to  substantiate  the  view  that  it  has  no 
inlluence  upon  the  secretions  of  the  stomach  or  pancreas.  Still, 
Michael  Foster  writes  as  follows :  "  After  a  meal  the  spleen  in- 
creases in  size,  reaching-  its  maximum  about  iive  hours  after  the 
taking  of  food ;  it  remains  swollen  for  some  time,  and  then  re- 
turns to  its  normal  bulk."* 

"  It  is  a  point  of  considerable  interest  that  the  spleen,  the  lym- 
phatic glands,  and  Pe^'cr's  patches  all  suffer  involution  at  the  same 
period  of  life — about  fifty.  At  that  time  the  spleen  grows  smaller, 
the  Ijmiphatic  glands  waste,  and  Peyer's  patches  smooth  down  and 
lose  their  peculiar  structure ;  and  that  is  about  the  period  of  life 
at  which  the  diseases,  and  especially  tj'phoid  fever,  in  which  these 
three  parts  are  involved,  cease  to  be  common. "t 

Some  interesting  observations  are  mentioned  by  Swedenborg.:]: 

Causes. — Enlargement  of  the  spleen  is  frequently  due  to  ague, 
and  hence  mostly  prevails  in  marshy  districts  along  with  inter- 
mittent fever.  Louis,  Murchison,  Warburton  Begbie,  and  many 
other  observers  have  noticed  it  diseased  in  tj^phoid  fever.  Disease 
of  the  liver,  as  cirrhosis,  or  whatever  obstructs  the  circulation  of 
the  spleen,  maj^  increase  its  bulk.  "It  is  often  greatly  enlarged  in 
European  children  who  are  resident  in  the  tropics."§  This  is  most 
likely  a  state  of  mere  hyperaemia,  but  long-continued  congestion 
ultimately  leads  to  enlargement  and  induration.  Obstructive  dis- 
ease of  the  heart,  emphj-sema  of  the  lungs,  by  causing  dilatation 
of  the  right  cavities  of  the  heart,  and  acute  tuberculosis  may  in- 

*  A  Textbook  of  Physiology,  1878,  p.  346. 

f  Clinical  Lectures  on  the  Diagnosis  of  Extra-pelvic  Tumors  of  the  Abdomen,  by 
Sir  W.  Jenner,  Bart.,  M.D.,  Brit.  Med.  Jour.,  1869,  vol.  i,  p.  113. 

X  On  the  Functions  of  the  Spleen,  ibid.,  \).  403. 

^  Reynolds's  System  of  Medicine,  article,  Diseases  of  the  Spleen,  by  J.  E.  Wardell, 
M.D.,  F.E.C.P.,  vol.  V,  p.  141. 
/ 


246  DISEASES   OF   CHILDEEX. 

diice  congestion  of  the  spleen.  In  the  latter  affection  I  have  seen 
a  few  caseous  deposits  of  considerable  size  both  in  this  organ  and 
the  liver,  when  the  lungs  have  been  studded  with  similar  tubercles 
and  the  diaphragm  honeycombed.*  An  enlarged  spleen,  associated 
with  rickets,  came  under  my  care  in  April,  1880,  in  the  case  of  a 
child  a  year  old,  the  spleen  reaching  to  the  ilium  below,  and  on 
its  inner  border  to  the  umbilicus.  Althousrh  mechanical  conges- 
tion  may  be  one  cause  of  the  hypertrophy,  it  more  frequently 
arises  from  some  morbid  condition  of  the  blood,  from  endocarditis, 
giving  rise  to  infarctions,-}-  from  syphilis,:}:  from  fevers,§  from 
anaemia, II  but  in  many  instances  it  undergoes  enlargement  without 
assignable  cause.  On  section  it  is  soft,  vascular,  and  of  a  dark-red 
color.  A  healthy  woman  and  her  husband  had  six  children,  three 
of  whom  had  disease  of  the  spleen.  One  child,  a  boy,  was  noticed 
to  have  a  large  spleen  when  fifteen  months  old,  and  he  lived  to  be 
nine  years  and  a  half  old.  Epistaxis  began  at  the  age  of  five  years, 
and  continued  to  recur  periodically  about  once  a  month.  A  second 
child  (whom  I  saw  in  August,  1880),  ten  years  of  age,  bled  from 
the  nose  in  the  same  way,  and  quite  as  profusely. "f  A  third  child, 
a  girl  one  year  old,  had  an  enlarged  spleen,  extending  to  the  ilium 
and  umbilicus.  It  had  only  been  detected  five  weeks.  All  these 
children  were  ravenous  for  food.  The  spleen  has  also  been  found 
hypertrophied  in  some  cases  of  leucocyth?emia  {splenic  leucocythce- 
mia),  and  in  this  afiection  it  attains  a  great  size.  Dr.  Taylor  has 
recorded  the  case  of  a  boy,  twelve  years  of  age,  who  died  from  this 
disease,  and  whose  spleen  was  found  to  weigh  51  ounces.** 

Diagnosis. — As  the  abdominal  wall  in  children  is  not  covered 
with  much  fat,  and  the  muscles  are  thin,  the  diagnosis  of  enlarged 
spleen  is  far  easier  in  them  than  in  adults.     Some  care,  however, 

*  "  Tubercle  occurs,  for  the  most  part,  in  the  spleen  only  in  acute  universal  tubercu- 
losis ;  it  occurs  more  frequently  in  children  than  in  adults,  in  the  proportion  of  40  to 
13.  It  appears  both  in  the  form  of  gray  granulations,  yellow  miliary  tubercles,  or 
yellowish  cheesy  masses,  of  the  size  of  a  pea  and  above." — Jones  and  Sieveking's  Path. 
Anat.,  by  Payne,  1875,  p.  657. 

f  Vide  Chap.  LI,  On  Ulcerative  Endocarditis. 

X  Vide  Chap.  L,  On  Syphilis.  ?  Vide  Chap.  VII,  On  Fevers. 

II  Vide  Chap.  LI,  On  Annemia. 

^  "In  nearly  all  affections  of  the  spleen  nasal  haemorrhage  is  a  common  symptom, 

and  among  ancient  physicians,  and  to  tliis  day  among  the  people,  repeated  bleeding 

of  the  nose,  especially  if  from  tlie  left  nostril,  is  taken  for  an  almost  pathognomonic 

symptom  of  such  disease." — Nievieyer's  Textbook  of  Practical  Medicine,  1875,  vol.  i,  p.  293. 

**  Path.  Trans.,  vol.  xxv,  p.  253. 


DISEASES   OF  THE  SPLEEN.  247 

is  necessary  not  to  mistake  for  an  enlarged  spleen  an  abdominal 
tumor  caused  by  enlargement  of  the  kidney  or  liver,  or  by  disease 
of  the  mesenteric  glands.  In  forming  an  opinion  of  tumors  in  this 
situation,  it  is  well  to  glance  at  the  anatomical  position  of  the 
spleen.  It  lies  hidden  in  the  left  hypochondrium  under  cover  of 
the  ribs,  between  them  and  the  stomach.  When  healthy  it  cannot 
be  felt  through  the  abdominal  parieles;  if  it  can  it  is  diseased. 
Moreover,  it  is  influenced  by  the  respiratory  movements. 

An  enlarged  spleen  may  extend  inwards  to  the  epigastrium  and 
umbilicus.  In  some  children  it  reaches  down  to  the  spine  of  the 
ilium.  The  tumor  is  smooth,  elastic,  and  firm,  and,  being  situated 
just  beneath  the  integument,  its  shape  and  firmness  can  generally 
be  well  ascertained.  In  cases  of  difficult  diagnosis  the  history  of 
asfue  would  be  of  much  assistance.  Sir  W.  Jenner  has  seen  a 
tumor,  supposed  to  be  fecal,  which  turned  out  to  be  "a  big  spleen, 
and  the  child  was  purged  for  it  till  it  had  bloody  stools."*  Tu- 
mors which  are  due  to  enlargement  of  the  kidney  do  not  cause 
any  projection  posteriorly  ;  the  expansion  takes  place  in  the  direc- 
tion in  which  they  meet  with  the  least  resistance,  and  that  is 
always  in  front, f 

Treatment — The  general  health  will. require  careful  attention 
to  maintain  it  at  the  best  possible  standard.  In  this  we  must  be 
guided  according  to  the  circumstances  and  surroundings  of  each 
individual  case,  the  strength  of  the  child,  the  stage  at  which  the 
disease  has  arrived,  and  the  complications  it  may  have  produced. 
If  inflammatory  symptoms  are  present,  and  there  is  any  degree  of 
acute  pain,  thirst,  dyspnoea,  etc.,  poultices  and  fomentations,  and 
even  two  or  three  leeches,  applied  over  the  affected  part,  may  be 
necessary  to  reduce  congestion  of  the  gland.  If  the  skin  is  hot 
and  dry,  and  there  is  any  degree  of  fever,  saline  aperients  (Form. 
8-41)  to  unload  the  bowels  and  drain  the  portal  system  will  be 
needed.  When  all  acute  symptoms  have  departed,  the  use  of 
iodine  externall}^,  in  the  shape  of  ointment  (Ung.  lodi.),  and  the 
iodide  of  potassium  internally  may  be  demanded.  Very  frequently 
a  cachectic  state  of  the  system  exists,  arising  from  ague,  syphilis, 
or  rickets,  and  these  conditions  must  be  met  by  suitable  remedies, 
such  as  arsenic,  mild  mercurials,  quinine,  etc.,  continued  for  a  long 

*  Clinical  Lectures  on  the  Diagnosis  of  Extra-pelvic  Tumors  of  the  Abdoruen,  Brit. 
Med.  Journ.,  1869,  vol.  ii,  p.  43. 

f  See  Chap.  XXIV,  Hydronephrosis. 


248  DISEASES    OF    CHILDEEX. 

time.  ]Mr.  Tyson,  of  Folkestone,  has  recorded  a  "  Case  of  Syphi- 
litic Enlarged  Spleen  in  a  Child."  At  two  years  of  age,  the  spleen 
reached  to  the  crest  of  the  ilium,  and  nearly  to  the  umbilicus. 
A  grain  of  gray  powder  was  given  night  and  morning,  and  one 
grain  of  iodide  of  potassium  with  ten  minims  of  the  sj'rup  of 
iodide  of  iron,  three  times  a  day.  In  three  months  the  spleen  was 
smaller,  and  two  months  later  it  only  extended  an  inch  below 
the  maro;in  of  the  ribs.  The  remedies  were  given  for  about  a 
year,  when  the  spleen  was  imperceptible,  and  the  child's  health 
excellent.* 

In  a  large  number  of  cases,  an8smia  is  so  marked,  and  the  consti- 
tution so  reduced,  that  the  patients  lose  Hesh,  and  gradually  sink 
away  exhausted.     Chalybeates  are  of  course  indicated. 


CHAPTER  XXIY. 

DISEASES    OF    THE    KID>:ETS    AXD    URI^TARY    ORGAXS. 

Theories  of  the  urinary  secretion — Remarks  on  the  urine — Congestion  of  the  kidneys  (active 
and  passive) — Temporary  and  intermittent  albuminuria — Treatment  of  congestion. 
AcrxE  Desquamative  Nephritis  :  Local  and  constitutional  symptoms — State  of 
urine  and  appearances  under  the  microscope — Scarlet  fever  the  most  frequent  cause. 
Pathology:  Morbid  anatomy.  Progi^osiS:  Case  of  acute  desquamative  nephritis 
from  cold  and  exposure,  terminating  in  chronic  albuminuria.  Treatment  :  Value 
of  small  doses  of  perchloride  of  mercury  and  perchloride  of  iron  in  the  congestive  stage. 

TnE  renal  affections  of  children  are  less  frequent  than  manj^  of 
the  ailments  to  which  early  life  is  liable,  but  there  hangs  about 
them  an  obscurity  which,  in  a  physiological  point  of  view,  is  per- 
plexing, and  in  a  clinical  one,  difficult  to  reconcile  with  our  knowl- 
edge of  disease,  and  of  the  active  functions  which  the  kidneys 
possess  when  health  is  continuously  maintained. 

In  order  to  understand  the  disorders  to  which  the  kidney  is 
liable,  it  is  well  to  glance  at  the  renal  apparatus  in  health,  and  to 
see  how  the  ditlerent  structures  are  concerned  in  the  elimination 
of  morlud  elements  from  the  blood. 

Beale  and  Johnson  say  the  water  is  first  eliminated  from  the 
blood,  and  the  urine  salts  are  gradually  added  as  the  water  pa.sses 

*  Tlie  Lancet,  1880,  vol.  ii,  p.  653. 


DISEASES   OF   THE   KIDNEYS   AND   URINARY   ORGANS.  249 

down  the  tubules.  Ludwig,  Brunton,  and  others,  entertain  the 
view  that  the  water  of  the  blood,  holding  the  different  salts  in 
solution,  is  first  squeezed  out  in  a  very  diluted  form,  and  that  the 
absorption  of  water  goes  on  through  the  epithelial  lining  of  the 
tubules,  the  urine  thus  becoming  more  concentrated  as  it  passes 
down  the  tubules.  The  former  assert  that  the  function  of  the 
epithelial  cells  of  the  tubules  is  to  excrete  urine  salts,  while  the 
latter  assert  that  their  true  function  is  to  absorb  w^ater. 

There  are  two  facts  which  stand  in  a  very  significant  relation  to 
these  views  :  one,  that  after  copious  draughts  of  water  the  epithe- 
lial cells  do  not  exert  themselves  in  absorbing  water  freely,  and  so 
the  urine  is  copious  and  of  low  specific  gravity,  while  during  thirst 
the  epithelial  cells  absorb  w^ater  more  a'ctively,  and  the  urine  is 
scanty  and  contains  excess  of  salts.  The  other  fact  is  that  in 
cirrhosis  of  the  kidney,  where  the  tubules  are  denuded  of  epithe- 
lium, the  urine  is  copious  and  of  low  specific  gravity. 

The  importance  of  this  subject  practically,  is  the  question  as  to 
whether  the  urine,  when  first  squeezed  into  the  glomeruli,  is  albu- 
ndnous  or  not.  According  to  the  view  of  Ludwig  and  others,  it  is 
primarily  albuminous  in  a  faint  degree,  and  the  albumen  is  reab- 
sorbed along  with  much  of  the  water  by  the  epithelial  cells  of  the 
tubules.  According  to  the  other  view,  albumen  is  thrown  out 
along  with  the  urine  salts  in  disease  of  the  urinary  tubules.  The 
question  has  not  yet  been  settled,  but  the  view  of  Ludwig  seems 
more  feasible,  and  consistent  with  the  known  fact,  that  albumen 
appears  in  the  urine  when  the  tubules  are  diseased. 

On  the  assumption  that  the  epithelial  cells  normally  reabsorb 
albumen  as  well  as  water,  w^e  can  readily  understand  how,  in  cer- 
tain conditions,  albumen  is  present  in  the  urine.  When  the  tubules 
are  the  subject  of  inflammation,  they  lose  their  power  to  reabsorb 
albumen,  consequently  albuminuria  is  constantly  found  in  tuljular 
nephritis,  as  we  see  commonly  after  scarlet  fever.  AVe  can  there- 
fore understand  how  temporary  derangement  of  the  epithelial 
lining  of  the  tubules  may  he  followed  by  the  appearance  of  albumen 
in  the  water.  Such  a  condition  may  exist  without  the  kidneys 
being  necessarily  organically  diseased.  In  cases  of  albuminuria, 
then,  the  question  arises,  whether  the  passage  of  albumen  in  the 
water  is  due  to  conditions  of  temporary  derangement,  or  to  struc- 
tural disease  of  the  kidneys. 

Li  the  treatment  of  sick  children,  a  constant  observation  of  the 


250  DISEASES   OF    CHILDREX. 

urine  is  as  important  as  in  the  management  of  disease  in  adult  life. 
At  all  ages  morbid  conditions  affect  the  secretion  of  the  kidneys, 
and  childhood  is  no  exception  to  this  rule.  Even  when  not  on  the 
sick-bed,  the  insidious  effects  of  errors  of  diet,  and  other  bad 
habits,  are  first  shown  in  alterations  of  the  amount  of  daily  excre- 
tion of  urine,  and  in  changes  in  its  constituents.  Intemperance, 
the  chief  vice  of  man,  directly  affects  the  kidne3's,  so  that  the 
reveller  longs  to  make  water  after  a  banquet.  Gluttony,  and  the 
preference  for  rich,  rather  than  wholesome  food,  are  the  com- 
monest failings  in  childhood.  Hence  the  turbid  urine  passed  by 
children  subject  to  gastric  and  intestinal  irritation  through  over- 
indulgence in  sweets  and  pastry.  Ignorance  of  the  evil  effects  of 
draughts  of  cold  air,  and  wet  feet,  renders  children  liable  to  catar- 
rhal affections,  which  produce  changes  in  the  urine. 

For  some  obscure  reason,  calculus  is  not  rare  among  boys  in  the 
humbler  ranks  of  society,  possibly  because  their  skin  and  lungs  are 
hardened  against  chill,  whilst  during  customary  exposure  to  cold 
their  kidneys  become  congested;  on  the  other  hand,  children  of 
gentle  breeding,  have  often  weaker  lungs,  but  through  efficient 
clothing  they  are  less  liable  to  contraction  of  the  bloodvessels  of 
the  skin,  and  to  consequent  increased  pressure  on  the  kidneys. 
Lastly,  it  is  in  childhood  that  reflex  and  emotional  influences  act 
so  strongly  on  the  renal  secretion.  The  phenomena  of  enuresis, 
and  of  loss  of  control  over  the  bladder,  from  the  very  fear  of  that 
accident,  are  almost  peculiar  to  childhood  in  civilized  lands,  where 
the  adult,  even  among  the  lowliest,  learns  self-control,  or  through 
experience,  adopts  precautions.  An  antiquated,  coarse  expres- 
sion, common  to  most  countries,  shows  that  in  former  less  refined 
states  of  society  the  involuntary  escape  of  urine,  as  the  result  of 
fear,  was  not  rare  in  adults.  It  is  physiologically  most  interest- 
ing to  observe,  on  the  other  hand,  the  great  delicacy  of  even  very 
young  well-bred  children  in  this  country  with  regard  to  micturi- 
tion. A  gentleman  taking  his  little  girl  out  for  a  walk,  is  often 
astonished  to  find  that  when  the  child  shows  sj'mptoms  of  desire 
to  pass  water  she  cannot  be  persuaded  to  do  so  in  the  0[)en  air, 
and  indeed  feels  much  hurt  at  any  attempt  at  persuasion  of  a 
kind  which  previously  she  has  only  heard  from  her  nurse  or 
mother.  An  infant  is  often  assisted  in  micturition  by  being 
hummed  to,  or  coaxed,  a  practice  very  similar  to  the  method  em- 


DISEASES    OF    THE    KIDNEYS    AND    UEINAEY   ORGANS.  2^1 

ployed  by  a  rider  when  he  desires  his  horse  to  stale  at  a  moment 
convenient  to  himself. 

Since  very  slight  disturbances  produce  feverishness  in  childhood, 
and  since  high  temperature  involves  the  excretion  of  concentrated 
urine,  that  fluid  will  almost  always  be  found  to  be  ahove  the  normal 
specific  gravity  in  a  children's  ward,  its  acid  reaction  is  likewise 
well  marked  under  these  circumstances.  In  fever  among  children, 
the  thick  and  almost  milky  urine,  turbid  when  passed,  not  merely 
turbid  when  cool,  is  highly  characteristic.  The  turbidity  is  dis- 
solved but  slowly  on  boiling  in  a  test-tube,  for  it  is  due  to  the 
urate  of  soda,  insoluble  in  cold,  and  only  Sjiaringly  soluble  in  hot 
water.  In  many  febrile  diseases,  however,  children  pass  clear 
urine,  which  on  cooling  throws  down  the  well-known  deposit  so 
readily  redissolved  on  boiling  in  a  test-tube.  In  this  deposit  the 
more  soluble  urate  of  ammonia  predominates. 

The  urine  of  a  child  sufiering  from  acute  scarlatinal  nephritis  is 
very  rich  in  morbid  products.  It  is  smoky,  or  almost  brothlike, 
from  the  presence  of  altered  blood,  and  throws  down  a  deposit  rich 
in  epithelial  casts,  and  in  the  beautiful  light-yellow  rhomboidal 
crystals  of  uric  acid.  Such  urine  must  be  carefully  examined  day 
after  day,  and  its  gradual  return  to  a  normal  condition  will  be  a 
valuable  guide  to  the  treatment  of  the  case.  Phosphates  are  often 
found  in  the  urine  of  nervous  and  sick  children,  and  in  such  cases 
the  fluid  may  be  copious  and  below  the  normal  specific  gravity  ; 
oxalates  may  also  be  found  in  pale  abundantly  excreted  urine. 
Mucus  is  frequently  deposited  in  the  urine  of  children  suffering 
from  paraplegia,  from  spina-bifida,  or  from  local  causes,  such  as 
calculus,  and  is  an  unfavorable  symptom,  since  it  may  denote  seri- 
ous changes  in  the  genito-urinary  tract ;  the  presence  of  pus  is  due 
to  the  same  causes  as  in  adults.  In  cases  of  enuresis  the  condition 
of  the  urine  must  be  carefully  examined  ;  when  a  morbid  salt  is 
discovered  the  administration  of  a  drug  which  counteracts  its  for- 
mation often  cures  the  patient,  as  the  presence  of  such  a  salt  in 
the  bladder  may  alone  cause  the  complaint. 

That  attention  which  is  now  paid  to  the  urine  in  adults  when  ill 
has  not  extended  as  far  as  it  should  do  to  the  examination  of  urine 
in  children.  With  the  exception  of  the  albuminuria  of  scarlet 
fever  the  profession  as  a  body  knows  little  of  these  modifications 
of  the  urine  produced  by  disease  in  children.  There  seems  to  ex- 
ist a  widespread  impression  that  changes  in  this  secretion  are  only 


252  DISEASES    OF    CHILDREN. 

important  in  adult  and  advanced  life,  an  impression  which,  to  my 
mind,  is  erroneous  and  ill-founded. 

In  the  present  state  of  our  knowledge  we  are  not  able  to  draw 
any  satisfactory  inferences  from  the  specific  gravity  of  the  urine 
in  children.  I  found  that  in  242  cases  admitted  into  the  Samar- 
itan Hospital  under  my  care,  the  highest  specific  gravity  reached, 
was  1034,  in  four  cases.  1.  Epileptoid  seizures;  2.  Congestive 
headache  ;  3.  Tuberculosis ;  4.  Catarrh.  In  all  these  four  cases 
the  urine  was  pale,  scanty,  and  very  acid.  The  lowest  specific 
gravity  was  1006,  in  a  boy  six  years  of  age,  on  the  fifth  day  of 
typhoid  fever,  when  it  became  pale,  clear,  and  alkaline.  After 
taking  small  doses  of  hydrochloric  acid  for  five  days,  the  reaction 
became  acid,  and  the  specific  gravitj^  reached  1018.  The  urine  was 
never  turbid,  nor  threw  down  a  deposit,  notwithstanding  that  the 
temperature  reached  103.6°.  In  states  of  debility,  and  in  some  cases 
of  mitral  disease,  the  specific  gravity  fell  to  1010.  The  average 
specific  gravity  of  the  whole  242  eases  was  1023,  and  instances  of 
this  were  furnished  in  anaemia,  debility,  pleurodj'uia,  rickets, 
phthisis  and  headache.  In  only  32  was  the  specific  gravity  under 
1020  ;  57  had  a  specific  gravity  of  1030,  or  over.  In  38  there  w^ere 
phosphates.  In  none  was  sugar  found.  In  three  cases  only  were 
there  large  "cayenne  pepper  crystals,"  and  these  were  in:  1.  A 
case  of  tuberculosis,  where  the  urine  w^as  highly  acid,  pale,  and 
scanty.  2,  Lobular  pneumonia.  3.  Chronic  albuminuria.  A  girl 
sufiering  from  chronic  mitral  disease  became  very  nervous,  and 
afterwards  her  urine  threw  down  a  o-reat  deal  of  uric  acid. 

There  was  only  one  case  of  chronic  albuminuria  in  the  whole 
242  cases,  and  this  occurred  in  a  strumous  girl,  nine  years  of  age. 
The  specific  gravity  varied  from  1016  to  1020,  and  the  microscope 
showed  irregular-sided  granular  casts,  some  uric  acid,  epithelial 
cells,  and  broken-down  blood-corpuscles. 

Congestion  of  the  kidneys  is  one  of  the  most  important  disorders 
to  which  these  organs  are  liable.  It  is  a  common  attendant  on 
many  ailments  of  children,  passing  away  with  the  recovery  of  the 
patient,  and  leaving  neither  inconvenience  nor  structural  change 
behind  it. 

In  measles  and  scarlatina,  as  well  as  in  many  inflammatory  dis- 
eases, there  is  a  determination  of  blood  to  the  internal  organs,  and 
active  congestion  of  the  kidneys  is  of  frequent  occurrence.  In 
measles  it  is  often  slight;  it  is  notably  more  marked  in  some  cases 


DIFEASES   OF   THE   KIDNEYS   AXD    URIXAEY   ORGANS.  253 

of  scarlet  fever,  and  there  is  a  considerable  amount  of  blood  with 
casts  of  the  uriniferous  tubes  and  epithelial  cells,  so  that  the  urine 
is  albuniinons.  This  is  a  point  I  shall  more  particularly  consider 
when  I  come  to  speak  of  a  state  of  congestion  of  the  kidney, 
brought  on,  not  by  the  scarlatinal  poison,  but  by  exposure,  bad 
living,  impure  air,  and  the  strumous  habit. 

The  passive  form  of  congestion,  as  in  adults,  is  most  common  in 
mitral  regui-gitation,  and  other  valvular  diseases  of  the  heart;  in 
emphysema,  pneumonic  conditions,  pleuritic  eifusion,  or  disease  of 
the  liver,  pressing  on  the  vena  cava.  This  form  of  venous  con- 
gestion is  owing  to  an  impediment  through  the  systemic  veins. 
The  i^assage  of  blood  through  the  kidney  is  slow,  and  congestion 
takes  place,  the  urine  is  scanty  and  high-colored  or  turbid,  and 
more  or  less  impregnated  with  albumen.  In  obstructive  disease 
of  the  heart,  the  fulness  of  the  venous  system  distends  the  renal 
veins,  and  the  Malpighian  capillaries  becoming  engorged,  a  transu- 
dation of  serum  takes  place  through  their  walls,  rendering  the 
urine  albuminous.  When  the  walls  of  the  capillaries  are  ruptured 
from  this  overdistension,  blood  is  mixed  with  the  urine,  and  blood 
casts  are  visible. 

The  first  efi'ect  of  passive  congestion  is  to  cause  enlargement  of 
the  gland,  and  ultimately  contraction  and  atrophy,  the  surface  of 
the  kidney  becoming  uneven,  and  finely  granular  as  the  wasting 
process  goes  on.     (Johnson.) 

The  treatment  consists  in  relieving  the  circulation  by  hydragogue 
cathartics,  absolute  rest,  and  tapping  of  the  chest  or  abdomen,  if 
there  is  a  lar2;e  accumulation  of  fiuid,  and  it  cannot  be  o:ot  rid  of 
in  anj^  other  way. 

Experimental  research  has  long  demonstrated  the  fact,  that  a 
ligature  placed  round  the  renal  vein,  obstructing  the  return  of 
blood,  causes  the  kidney  to  increase  in  volume,  and  the  urine  to 
contain  albumen,  casts  of  the  uriniferous  tubes,  and  renal  epithe- 
lium. Hence  the  liability,  in  inflammatory  disorders,  and  checked 
cutaneous  action,  for  the  kidneys  to  become  congested,  like  other 
organs,  and  so  to  create  a  disturbance  in  the  intricate  and  nicely 
adapted  circulation  through  the  Malpighian  tufts,  and  plexus  of 
capillaries,  which  surround  the  uriniferous  tubes. 

Some  cases  of  intermittent  albaminuria  are  due  to  congestion  of 
the  renal  vessels,  or  to  loss  of  tone  in  them.  An  interesting  case 
of  this  kind  is  alluded  to  by  Dr.  Morley  Rooke,  of  Cheltenham. 


254  DISEASES   OF   CHILDREIf. 

There  were  no  renal  products  under  the  microscope,  the  albumen 
disappearing  with  rest,  but  returning  when  the  patient  assumed  a 
vertical  position.* 

In  children,  as  in  adults,  the  injudicious  use  of  mercury  may 
produce  temporary  albuminuria,  either  by  setting  up  some  blood 
change,  or  inflammatory  condition  of  the  renal  structures.  It 
passes  away  when  the  remedy  is  discontinued.  Other  irritants  or 
substances,  which  find  their  way  out  of  the  system  by  the  kidneys 
chiefly,  as  lead  and  alcohol,  have  the  same  effect. 

Acute  Desquamative  Nephritis. — The  disease  follows  the  same 
course  and  presents  similar  sj^mptoms  in  children  to  adults.  The 
symptoms  are  those  of  general  febrile  action  with  a  temperature 
which  may  reach  104,t  with  quick  throbbing  pulse,  thirst,  head- 
ache, and  loss  of  appetite.  There  is  pain  in  the  loins  and  legs,  and 
in  a  few  days  the  face  is  pale  and  shrunken,  the  eyelids  are  pufty, 
so  that  the  eyes  cannot  be  seen,  general  anasarca  or  dropsy  sets  in 
early,  and  the  hands  and  lower  limbs  are  oedematous ;  eiiusion 
into  the  pleural  sacs,  pericardium,  or  abdomen,  are  common,  and 
pneumonia  is  occasionally  present.  At  first  the  urine  is  scanty  or 
almost  entirely  suppressed ;  it  is  dark  from  the  presence  of  blood, 
and  contains  a  thick  sediment.  If  there  is  pain  across  the  loins, 
or  deepseated  tenderness  on  pressure,  more  or  less  blood  will  often 
be  seen,  or  detected  under  the  microscope,  with  tube-casts,  and 
renal  epithelium.  The  patient  is,  restless  and  talkative  in  sleep, 
and  if  the  urine  does  not  increase  in  quantitj^,  the  poisoned 
elements  in  the  blood  will  sometimes  lead  to  convulsions,  delirium, 
or  coma.  Convulsions  are,  however,  infrequent  in  the  albuminu- 
ria of  children.  As  the  disease  progresses,  and  congestion  of  the 
kidneys  diminishes,  the  urine  becomes  pale  and  increased  in 
quantity,  and  the  anasarca  gradually  disappears.     Notwithstand- 

*  Brit.  Med.  Jonrn.,  Manchester  Meeting,  Aug.,  1877. 

See  Clironic  Desquamative  Neplirilis,  p.  264. 

"  Under  ordinary  circumstances  albuminous  bodies  do  not  diffuse  through  animal 
membranes,  but  it  has  been  shown  by  Bernard,  Pavy,  Stockvis,  and  others,  that 
albumen  of  eggs  will  pass  out  through  the  kidneys,  while  the  albumen  of  blood  does 
not  do  so  under  similar  conditions"  (Dr.  Lauder  Brunton). — Practitioner,  June,  1877, 
p.  427. 

t  This  high  temperature  appears  to  be  unusual.  Dr.  Dickinson  mentions  that  he 
ha.s  no  thermometric  record,  at  the  outset  of  this  disease,  of  more  than  a  few  points 
above  100°.  When  uncomplicated,  lie  has  known  the  temperature  to  range  for  many 
weeks  between  97.5°  and  99.5°. — Diseases  of  the  Kidney,  part  2,  Albuminuria,  1877, 
p.  278. 


DISEASES   OF   THE   KIDNEYS   AND   URINARY   ORGANS.  255 

ino-  this,  the  albumen  may  be  equally  great  in  amount,  and  any 
error  in  diet,  or  cold,  will  renew  the  renal  congestion  and  hsema- 
turia. 

The  microscopical  appearances  of  the  urine  show  epithelial 
casts  of  the  uriniferous  tubes.  In  these  casts  are  to  be  seen  blood- 
corpuscles  and  renal  gland  cells,  besides  small  and  large  hyaline 
casts,  but  these  are  often  indistinct,  and  cannot  be  seen  for  weeks 
together,  even  when  there  is  a  large  amount  of  albumen.  The 
large  hyaline  casts  may  be  absent  altogether  (Johnson).  As  the 
disease  goes  on,  oily  casts  and  cells  are  detected  in  the  tube-casts, 
indicating  that  the  secreting  cells  of  the  kidney  are  undergoing 
fatty  change.* 

The  causes  of  this  affection  in  childhood,  are  most  frequently 
due  to  scarlatina  and  to  suppressed  action  of  the  skin  following 
exposure  to  wet  and  cold.  When  the  rash  of  scarlet  fever  is  out, 
or  the  skin  is  desquamating,  cutaneous  action  is  checked  by  cold, 
and  a  morbid  process  is  set  up  in  the  kidney.  The  circulation 
being  impeded,  the  urinary  constituents  accumulate  in  the  blood 
and  lead  to  dropsical  effusions.  It  is  generally  admitted  that  the 
more  severe  the  throat  affection  the  less  likely  are  the  kidneys  to 
become  affected  ;  but  it  must  be  borne  in  mind  that  when  the 
throat  is  very  sore  the  patient  is  treated  with  more  care,  and  is 
not  so  likely  to  be  exposed  to  cold,  which  would  cause  or  aggra- 
vate kidney  disease.  ,  Scarlatinal  dropsy  is  most  frequent  from  the 
tenth  to  the  fourteenth  day,  but  it  may  be  delayed  much  later. 
In  two  cases  under  my  care,  about  the  same  time,  the  symptoms 
came  on  in  one  case  at  the  end  of  the  fifth  week,  and  in  the  other 
case  at  the  seventh  week. 

Nephritis  in  children  has  also  been  observed  in  connection  with 
pneumonia,  rheumatic  fever,  small-pox,  typhoid  fever,  chronic 
dyspepsia,  and  the  consumption  of  indigestible  food.  Next  to 
scarlatina,  diphtheria  and  measles  are  the  most  common  causes. 

Scarlatina  then  is  the  most  frequent  cause  of  acute  nephritis, 
the  kidneys  being  irritated  as  they  assist  in  the  removal  of  morbid 
products  from  the  blood.  This  unhealthy  stimulation  throws  upon 
these  organs  work  to  which  they  are  unaccustomed,  and  as  a  con- 
sequence they  become  congested,  and  the  tubes  choked  up  with 

*  For  farther  information  on  this  subject  the  reader  is  referred  to  Dr.  George  John- 
son's Lectures  on  Bright's  Disease,  1873 ;  Dr.  Roberts  on  Urinary  and  Renal  Diseases, 
1877  ;  and  Dr.  Dickinson  on  Diseases  of  tlie  Kidney,  part  2,  Albuminuria,  1S77. 


256  DISEASES    OF   CHILDREN'. 

exudation.  If,  at  the  same  time,  the  patient  is  exposed  to  wet 
and  cold  during  the  shedding  of  the  cuticle,  symptoms  of  acute 
renal  disturbance  are  set  up  and  dropsy  follows.  Dr.  Dickinson 
writes :  "  That  at  the  Children's  Hospital  where  children  are 
treated  up  to  twelve,  a  series  of  103  cases  of  albuminuria  connected 
apparently  with  renal  inflammation,  gave  75  where  the  disorder 
was  traced  to  scarlatina,  3  to  measles,  1  to  erysipelas,  1  to  acute 
rheumatism,  and  1  in  which  it  came  on  in  the  course  of  eczema ; 
5  from  cold,  and  17  from  uncertain  causes  made  up  the  tale."* 

Boys  are  more  liable  to  scarlatinal  dropsy  than  girls,  just  as 
adult  males  are  more  prone  to  kidney  disease  than  females.  The 
greatest  frequenc}^  in  children  is  between  the  ages  of  live  and 
fifteen.  "  There  are  two  periods  which  are  especially  amenable  to 
the  disease.  The  scarlatinal  form  is  most  common  under  ten  years 
of  age  ;  the  form  which  results  from  cold  is  especially  apt  to  occur 
between  twenty  and  thirty.'^f  The  association  of  tuberculosis 
with  this  disease  is  extremely  uncommon. 

Pathology. — In  consequence  of  suppressed  skin  action  the  kid- 
neys become  congested  through  having  to  take  on  increased  func- 
tional activity,  whereby  the  organs  become  congested  and  swollen. 

Hyperplasia  of  the  epithelial  cells  in  the  tubules  then  takes 
place,  and  these  cells  are  incapable  of  separating  the  solid  urinary 
constituents,  which,  remaining  in  the  blood,  give  rise  to  the  well- 
known  symptoms  already  described.  Hence. effusion  takes  place 
in  the  various  tissues  and  serous  sacs  of  the  body.  The  blood 
undergoes  changes,  in  becoming  poor  and  thin,  faUing  in  specific 
gravity,  whilst  albumen  and  blood  appear  in  the  urine  from  dila- 
tation and  rupture  of  the  renal  capillaries.  For  some  time  urea  is 
eliminated  by  the  vomiting  and  diarrhoea  that  ensue  ;  but  when 
these  functions  fail,  the  gradual  accumulation  of  excrementitious 
urinary  compounds  in  the  blood  occasions  convulsions  or  coma. 

Morbid  Anatomy. — If  death  takes  place  during  the  acute  stage 
the  kidneys  are  found  congested  and  enlarged  ;  they  are  of  a  dark- 
red  or  chocolate  color,  the  cortex  is  mottled  with  spots  of  anremia 
and  is  ecchymosed,  and  the  medullary  cones  are  dark  and  con- 
gested. The  uriniferous  tubes  are  crowded  with  epithelial  cells 
and  blood,  the  walls  of  the  capillaries  are  thickened,  and  conges- 
tion of  the  pelvis  of  the  kidneys,  ureters,  and  bladder  is  found  in 

*  Diseases  of  tlie  Kidney,  by  Dr.  Dickinson,  part  2,  Albuminuria,  p.  321. 
f  lb.,  part  2,  Albmninuria,  p.  2G8. 


DISEASES   OF   THE   KIDNEYS   AND   URINARY   ORGANS.  257 

addition  to  effusion  into  the  serous  sacs.  After  a  variable  period 
the  kidneys  in  some  cases  undergo  degeneration  (chro^iic  desquam- 
ative nephritis). 

Prognosis. — When  the  secretion  of  urine  is  free  and  there  is  not 
much  blood  or  albumen  mixed  with  it,  the  prognosis  is  favorable, 
and  many  cases  due  to  scarlatina  or  measles  completely  recover; 
but  if  the  albumen  is  in  excess  and  the  urine  is  deficient  in  quan- 
tity, or  the  child  is  of  a  strumous  constitution,  the  prognosis  is 
bad.  The  subjoined  case  is  a  good  example  of  acute  desquamative 
nephritis,  terminating  in  permanent  albuminuria  and  chronic 
change  of  structure. 

E.  S ,  pet.  9|,  a  fast-growing,  strumous-looking  girl,  was  ad- 
mitted into  the  Samaritan  Hospital  under  my  care  on  June  15th, 
1875,  suffering  from  acute  desquamative  nephritis  and  anasarca. 
The  parents  stated  she  had  never  had  scarlet  fever,  nor  had  the 
disease  prevailed  in  the  house  or  neighborhood.  The  case  seemed 
due  to  cold  and  exposure.  On  admission,  the  eyes  were  almost 
obscured  from  oedema  of  the  lids  ;  the  arms,  legs,  and  thighs  were 
tense  from  subcutaneous  infiltration,  and  there  was  free  fluid  in 
the  peritoneum.  There  was  slight  effusion  into  the  left  pleural 
sac  (about  a  quarter  of  a  pint) ;  the  first  sound  of  the  heart  was  a 
little  prolonged,  and  louder  than  usual,  but  the  valves  were  healthy. 
Temperature  100.1°,  pulse  120,  respiration  32.  The  mother  said 
that  she  noticed  her  daughter's  face  swollen  in  December,  1874, 
])ut  she  had  attended  school  regularly  till  a  month  before  admis- 
sion. 

The  urine  was  high-colored  and  turbid  ;  reaction,  acid;  sp.  gr. 
1010;  it  was  thick  and  clotty  on  boiling,  and  the  addition  of 
nitric  acid  rendered  the  whole  an  albuminous  curdlike  mass, 
adherent  to  the  test-tube. 

June  16th. — There  was  much  more  oedema  of  the  feet  and  legs, 
and  the  temperature  was  102-2°.  The  urine  was  thick,  scanty, 
and  dark-colored ;  only  twelve  ounces  were  passed  in  twenty- 
four  hours  (although  she  drank  freely  of  cold  water),  sp.  gr.  1030; 
on  the  application  of  heat,  the  urine  coagulated  in  large  and 
divided  clots.  The  addition  of  nitric  acid  converted  it  into  a 
thick,  soapy  mass,  which  admitted  of  the  tube  being  inverted, 
wliile  only  a  little  fluid  escaped.  Under  the  microscope,  there 
was  not  a  trace  of  blood-corpuscle,  urinary  cast,  or  epithelial  cell, 
which  is  unusual  with  this  albuminous  condition  of  the  urine. 

17 


258  DISEASES    OF   CHILDREN. 

She  was  ordered  a  mixture  of  tincture  of  digitalis  with  acetate  of 
potash,  aud  compound  jalap  powder  occasionally. 

19th. — The  temperature  had  risen  to  104°,  and  the  pulse  to 
140 ;  the  anasarca  had  much  increased,  and  there  was  great 
stupor  and  drowsiness.  A  third  of  the  urine  was  albuminous,  and 
on  standing  all  night  looked  like  barm.  The  microscope  now 
showed  large  epithelial  cells,  probably  from  the  straight  portion 
of  the  tubes,  and  numerous  blood-corpuscles,  some  of  them  altered 
and  shrunken  ;  a  few  epithelial  cells  from  the  convoluted  portion 
of  the  kidneys,  and  two  short  and  small  granular  casts.  There 
was  now  acute  nephritis,  with  a  limited  degree  of  desquamation. 

Three  days  later,  forty-four  ounces  of  pale  urine  were  passed  in 
twentj'-four  hours.  A  few  hyaline-looking  casts,  large  and  small, 
with  here  and  there  a  renal  gland  cell,  were  seen  under  the  micro- 
scope. Bark  and  hydrochloric  acid  were  now  substituted  for  the 
previous  mixture.  At  the  end  of  another  week,  seventy-five 
ounces  of  similar  urine,  with  a  low  specific  gravity,  were  passed 
in  twenty-four  hours.  The  tincture  of  the  perchloride  of  iron  was 
given  in  ten-minim  doses  three  times  a  day. 

During  the  remainder  of  her  stay  in  the  hospital  she  passed 
above  the  average  amount  of  nrine,  as  the  healthy  functions  of 
the  kidneys  were  in  slow  process  of  restoration. 

On  the  24th  of  July  she  left  the  hospital  feeling  quite  well,  and 
presenting  no  trace  of  dropsy.  The  presence  of  albumen  was 
doubtful. 

On  October  9th  of  the  same  year,  the  patient  was  readmitted 
with  symptoms  of  acute  desquamative  nephritis.  There  was 
much  anasarca  of  the  face  and  limbs,  which  increased  for  a  few 
days  after  admission  into  the  hospital.  The  urine  was  highly 
albuminous,  and  clotted  like  cream  on  the  sides  of  the  test-tube. 
The  deposit  contained  granular  casts,  indicating  the  desquamation 
of  cells  already  morbid;  moreover,  numerous  cayenne  pepper 
crystals  of  uric  acid  were  found,  proving  imperfect  elaboration  of 
the  nitrogenous  principles  in  the  blood,  from  reduced  functional 
activitj'  of  other  organs. 

In  November  she  caught  cold,  and  had  an  attack  of  acute  renal 
congestion,  followed  by  a  large  quantity  of  bloody  urine,  of  a 
bright  claret-color.  At  the  close  of  the  month,  the  urine  was 
still  dark,  containing  blood-corpuscles,  broken  irregular  granular 
casts,  and  some  fresh  renal  cells.     For  the  first  time  I  detected 


DISEASES   OF   THE   KIDNEYS   AND   UEINARY   ORGANS.  259 

increased  impulse  of  heart,  and  intensification  of  aortic  second 
sound.  The  J^  of  a  grain  of  perchloride  of  mercury  was  added  to 
each  dose  of  the  mixture.  There  was  a  slight  reduplication  of  the 
first  sound  over  the  interventricular  septum,  and  the  apex  beat 
was  lower  by  half  an  inch. 

JaTiuary  11th,  1876. — A  careful  examination  of  the  heart  re- 
vealed the  following  condition.  The  second  sound  was  intensified 
to  a  certain  extent  over  the  aorta,  and  to  a  greater  extent  over 
the  pulmonary  artery  in  the  second  left  intercostal  space.  There 
was  occasional  doubling  of  the  second  sound  over  the  conus  arteri- 
osus ;  there  was  no  doubling  of  the  first  sound  anywhere ;  cooing 
inspiration  was  audible  over  the  upper  lobes  in  front,  but  not 
behind.  Apex  beat  in  fourth  interspace,  and  impulse  extended 
to  outer  side  of  nipple.  The  pulse  did  not  present  the  feeling  of 
tension,  and  when  the  finger  was  lightly  applied  to  the  radial 
artery  it  felt  the  stroke  and  collapse.  Sphygmographic  tracings 
showed  moderate  tension  ;  greatest  sweep  at  about  150°  to  200°  ; 
systolic  rise  was  not  anywhere  greatly  prolonged. 

27th. — At  her  mother's  request,  the  patient  left  the  hospital,  her 
general  health  was  good,  and  all  dropsy  had  disappeared.  The 
urine  was  clear  and  acid,  sp.  gr.  1020;  it  contained  only  a  trace 
of  albumen.  This  favorable  change  was  attributable  to  the  per- 
chloride of  mercury,  which  she  had  continued  regularl}^  n-p  to  this 
time. 

June  11th,  1877. — She  was  perfectly  well  in  health,  and  had  re- 
mained so  ever  since  January,  1876.  She  had  never  any  headache, 
sickness,  or  diarrhoea,  and  her  mother  considered  her  as  well  as  at 
any  time  of  her  life.  She  was  fed  on  oatmeal  porridge  and  milk 
every  morning,  and  had  meat  three  times  a  week. 

Analysis  of  Urine. — Clear  bright  yellow,  with  mucous  cloud; 
sp.  gr.  1024 ;  faintly  acid  reaction.  Became  very  milky  with  heat, 
and  the  cloud  was  partially  cleared  with  eft'ervescence  by  the  ad- 
dition of  a  few  drops  of  nitric  acid  (phosphates).  Albumen  a 
sixth  part. 

The  microscope  showed  ordinary  squamous  epithelium,  and  a 
quantity  of  hyaline  tube-casts,  but  they  were  very  indistinct.  The 
high  specific  gravity  is  unusual  with  such  albuminous  urine.* 

*  There  are  several  points  in  which  this  case  is  both  suggestive  and  instructive, 
showing  as  it  does,  in  a  very  striking  manner,  that  the  presence  of  a  large  amount  of 
albumen  in  the  urine  is  not  incompatible  with  active  growth  of  the  body,  and  a  good 


2G0  DISEASES    OF    CHILDREN. 

As  a  rule,  children  recover  more  frequently  from  the  dropsy  of 
scarlatina  and  other  febrile  diseases,  than  from  that  which  is  due 
to  cold  and  constitutional  causes.  Usually  the  disease  terminates 
in  six  months,  but  it  may  assume  a  chronic  form,  and  be  indefi- 
nitely protracted;  the  interstitial  tissue  of  the  kidneys  increases, 
and  contraction  ensues.  Of  50  fatal  cases  under  the  age  of  sixteen, 
28  died  from  diseases  of  the  respiratory  organs,  including  pneu- 
monia, pleurisy,  bronchitis,  and  empyema.  Of  the  remaining  22 
cases,  death  was  caused  by  uremic  convulsions  in  8,  by  pleuritic 
effusion  in  5,  by  vomiting  in  3,  b}'  peritonitis  in  4,  by  pericarditis 
in  1,  and  by  sloughing  of  the  scrotum  in  1.  (Dickinson.) 

!Now  as  to  the  general  management  of  these  cases.  When  the 
primary  cause  of  the  disease  can  be  ascertained,  we  may  do  much 
in  mitigation,  or  cure  of  the  symptoms,  by  directing  careful  atten- 
tion to  all  those  points  which  bear  upon  the  original  malady.  If 
the  albumen  be  due  to  pressure  from  morbid  growths,  or  to  an  en- 
larged liver,  we  know  the  best  plan  to  adopt  in  mitigation  of  the 
evil;  and  if  the  thoracic  organs  are  unhealthj^,  they  may  induce 
renal  changes  through  obstruction  to  the  circulation.  AVe  may 
excite  the  action  of  the  skin  by  the  warm  bath,  and  by  diapho- 
retics ;  we  may  relieve  the  portal  circulation  by  efficient  purgation, 
and  thus  we  can  indefi^nitely  prolong  life  if  there  is  no  hope  of 
saving  it.     But  all  drugs  and  therapeutic  agents  are  secondary  to 

state  of  health.  When  such  cases  as  these  occasionally  come  under  close  observation, 
and  opportunities  are  afforded  of  studying  their  course  and  progress,  we  may  reasonably 
commit  ourselves  to  the  assertion,  that  whenever  a  large  amount  of  albumen  is  daily 
separated  from  the  blood  for  many  months,  it  must  indicate  pathological  changes  in  the 
renal  organs  of  a  chronic  and  incurable  nature. 

It  is  remarkable,  and  very  exceptional,  that  tlie  retained  urinary  excreta  should 
cease  to  give  rise  to  any  constitutional  symptoms  when  there  was  no  vicarious  discharge 
from  the  stomach  or  bowels  going  on,  to  wash  out  the  impurities  from  the  .system. 
There  was  no  flatulence,  dyspepsia,  or  any  complaint  whatever,  and  the  slender  ankles, 
healthy  features,  and  the  hue  of  the  countenance  indicated  a  return  to  health,  though 
the  patient  was  living  in  a  poor  home,  without  much  care  or  attention  to  diet 

In  this  case  we  may  explain  the  coexistence  of  albuminuria  with  good  general  health 
on  the  hypothesis,  that  a  mild  subacute  inflammation  of  one,  or  even  both  kidneys,  was 
at  one  time  going  on.  Such  a  condition  is  not  incompatible  with  an  almost  perfect 
functional  activity  of  the  kidneys  in  other  respects,  and  may  be  compared  with  clironic 
Ciitarrh  of  tlie  mucous  membrane  of  tlie  nose  and  bronclii,  where  inflammatory  prod- 
ucts are  discharged  for  years.  But  the  fact  must  not  be  overlooked,  in  this  and  similar 
cases,  that  continued  congestion,  whether  it  be  inflammatory  or  otherwise,  ultimately 
tends  to  modif}'  the  nutrition  of  the  kidney,  and  to  alter  the  glandular  structures,  so 
that  in  time  it  leads  to  atrophy  and  contraction  of  the  organ. 


DISEASES    OF   THE    KIDXEYS    AND    URINARY   ORGANS.  261 

diet,  for  the  closest  relation  exists  betwixt  the  solids  and  fluids 
taken  in  as  food,  and  the  condition  of  the  urinaiy  secretion. 

Treatment  of  Acute  Desquamative  Nephritis. — The  patient  should 
be  kept  in  bed,  and  the  temperature  of  the  apartment  maintained 
between  65^  and  70°,  but  well  ventilated,  and  free  from  currents 
of  cold  air.  In  all  cases,  and  particularly  where  the  secretion  of 
urine  is  scanty, diluent  drinks  should  be  taken  freely,  and  the  diet 
be  very  scanty.  For  children,  milk  is  the  only  nourishment  neces- 
sary, as  it  does  not  irritate  the  kidney.  If  the  milk  disagrees,  or 
the  patient  tires  of  it  after  a  time,  or  if  it  deranges  digestion,  or 
causes  constipation,  a  little  veal  broth  or  mutton  broth  must  be 
substituted,  and  barley-water,  sago,  or  arrowroot  are  useful,  but  in 
every  case  the  patient  must  soon  return  to  a  mik  diet.  Alcoholic 
stimulants  should  be  prohibited. 

To  reduce  the  inflammation,  cupping,  or  leeches  to  the  loins  may 
be  necessary,  if  the  child  is  strong  and  full  of  blood ;  but  if  there 
is  much  haemorrhage  from  the  kidney  the  patient  may  be  too 
weakened,  and  aperients  and  diaphoretics  will  be  safer.  A  diapho- 
retic mixture  containing  antimony,  or  a  solution  of  acetate  of  am- 
monia, will  determine  action  in  the  skin,  and  relieve  any  dropsical 
eft'usion  that  may  be  present.  It  is  important  to  unload  the  bowels 
well,  and  for  this  purpose,  a  purge  occasionally  of  compound  jalap 
powder,  will  relieve  arterial  tension  if  present,  and  rouse  the  kid- 
neys to  freer  action.  A  fair  allowance  of  fluid  should  be  taken  to 
wash  out  the  tubes,  and  to  prevent  their  obstruction.  In  this  way 
the  congestion  of  the  gland  is  relieved,  and  there  is  a  better  chance 
for  all  the  constituents  of  the  urine  to  escape.  "  Of  all  diuretics 
water  is  the  best "  (Dickinson),  and  it  may  be  taken  to  the  extent 
of  two  or  three  pints  daily.  The  bitartrate  of  potash  drink, 
flavored  with  lemon  and  sweetened  with  sugar,  is  very  agreeable ; 
whilst  it  helps  to  clear  the  renal  channels  of  morbid  secretions,  it 
keeps  the  bowels  free,  and  also  assists  in  relieving  the  contamina- 
tion of  the  blood. 

A  mixture  of  citrate  of  potash  and  tincture  of  digitalis  increases 
the  quantity  of  urine,  and,  so  far  as  my  experience  goes,  has  no 
tendency  to  aggravate  renal  congestion.  It  is  a  favorite  remedy 
with  me  when  the  secretion  is  scanty  and  high-colored,  or  contains 
blood,  although  Dr.  Dickinson  is  of  opinion  that  digitalis,  by  add- 
ing to  the  force  of  the  heart,  may  increase  the  discharge  of  blood. 


262  DISEASES    OF    CHILDEEN. 

In  the  form  of  infusion,  digitalis  is  a  good  diuretic,  and  one  or  two 
drachms  may  be  taken  three  times  a  day. 

In  the  early  stage  of  the  acute  affection,  warm  baths,  or  the  hot 
vapor-bath,  may  be  used  with  great  advantage,  and  they  are  par- 
ticularly suitable  for  children,  if  the  action  of  the  skin  is  defective, 
and  there  are  any  signs  of  cerebral  oppression.  The  sweating  that 
ensues  brings  immense  relief  to  the  system,  unloading  the  capil- 
lary circulation,  and  lessening  the  distension  of  the  renal  vessels. 
The  baths  may  be  employed  evevy  night  on  going  to  bed,  for  the 
first  few  nights,  and  then  less  frequently.  The  temperature  may 
vary  from  98°  to  lOO-",  and  the  child  may  be  immersed  from  10  to 
15  minutes.  Dr.  George  Johnson  speaks  highly  of  a  wet  sheet 
and  blanket  bath.  "A  sheet  is  wrung  out  of  warm  water,  and 
the  patient,  either  naked  or  covered  only  by  a  shirt,  is  enveloped 
in  the  wet  sheet  up  to  the  neck.  Then  three  or  four  dry  blankets 
are  closely  folded  over  the  wet  sheet.  He  may  remain  thus  packed 
from  two  to  four  or  six  hours,  or  even  longer.  Recently,  a  boy  in 
the  hospital  with  acute  renal  disease  and  almost  complete  sup- 
pression of  urine,  consequent  on  scarlet  fever,  was  kept  packed  in- 
cessantly for  four  days  without  serious  discomfort,  and  with  great 
relief  from  very  distressing  and  alarming  symptoms.  When  he 
left  the  hospital  all  traces  of  his  malady  had  disappeared.'"* 

If  head  symptoms  in  the  character  of  convulsions  or  coma  super- 
vene, we  may  generally  attribute  them  to  a  poisoned  state  of  the 
blood  (ursemiaj,  or  to  an  ansemic  state  of  the  brain  through  some 
source  of  exhaustion,  as  protracted  vomiting  or  diarrhcea.  Yet  it 
is  remarkable  that  son:ie  severe  cases  of  nephritis  in  children,  with 
an  enormous  escape  of  albumen  from  the  system,  are  not  accom- 
panied by  headache,  or  cerebral  symptoms  of  any  kind.  If  they 
are  present,  and  the  head  is  hot  or  painful,  cold  lotions  may  be 
applied,  or  a  mustard  poultice  to  the  nape  of  the  neck  will  be 
serviceable.  Bromide  of  potassium  or  chloral  may  be  needed  to 
calm  the  cerebral  irritation,  and  a  free  action  on  the  bowels  and 
kidneys  must  be  kept  up,  so  that  the  morbid  products  may  be 
gradually  eliminated  from  the  circulation.! 

*  Lectures  on  Briglit's  Disease,  1S73,  p.  133. 

t  "  I  offer  for  your  practical  guidance  this  rule  of  treatment :  wlien  such  symptoms 
as  headache,  delirium,  convulsions,  or  coma  are  the  results  of  uraemia,  give  purgatives 
freely;  and  if  the  renal  disease  be  acute,  and  therefore  probably  curable,  your  treat- 
ment will  often  be  completely  successful.     On  the  other  hand,  wlien  you  have  reason 


DISEASES   OF   THE   KIDNEYS   AND   URINARY   ORGANS.  263 

Inflammatory  complications,  as  pleurisy,  pericarditis,  bronchitis, 
and  peritonitis,  must  be  treated  on  general  principles,  always  re- 
membering that  the  kidney  disorder  is  the  cause  of  the  evil. 
Diaphoretics  and  local  applications,  with  careful  regulation  of  the 
diet,  are  the  remedies  to  be  relied  upon. 

When  the  acute  stage  has  passed,  and  there  is  passive  conges- 
tion of  the  kidney,  our  treatment  must  undergo  considerable 
change.  Of  all  remedies,  none  are  equal  to  small  doses  of  per- 
chloride  of  mercury,  combined  with  the  tincture  of  perchloride  of 
iron,  when  every  trace  of  blood  has  disappeared  from  the  urine, 
and  there  is  sufficient  albumen  to  justify  the  opinion  that  renal 
congestion  is  present.  I  have  known  epithelial  and  fibrinous  casts 
to  be  facilitated  in  their  escape  from  the  convoluted  tubules  of  the 
kidney,  when  these  remedies  have  been  continued  for  weeks,  and 
the  amount  of  albumen  to  undergo  a  marvellous  diminution.  When 
the  evidences  of  general  debilit}^  and  anaemia  are  most  prominent, 
the  perchloride  of  mercury  should  be  withdrawn,  and  the  iron  given 
alone.  In  some  cases,  the  vinum'  ferri,  or  the  acetate  of  iron,  may 
be  ordered  according  to  the  discretion  of  the  practitioner,  and  if 
there  is  a  deficiency  of  renal  secretion,  the  bitartrate  or  the  acetate 
of  potash  may  be  added. 

to  believe  that  the  like  brain-s^'mptoms  are  consequent  on  cerebral  haemorrhage,  or 
embolism,  or  thrombosis,  be  very  cautious  in  the  use  of  purgatives,  which  may  greatly 
increase  the  patient's  distress  and  exhaustion,  while  they  can  do  little  to  improve  his 
condition.  In  inflammatory  afl^ections  of  the  brain  and  its  membranes,  purgatives  are 
often  useful,  but  less  frequently  and  strikingly  so  than  when  cerebral  symptoms  are  the 
result  of  uraemia." — Lectures  on  Bright'' s  Disease,  by  G.  Johnson,  M.D.,  F.R.  S.,  1873, 
p.  136. 


264  DISEASES    OF   CHILDREN". 

CHAPTER    XXiy  {continued). 

DISEASES   OF    THE   KIDNEYS  AND   URINARY    ORGANS. 

Chronic  Desquamative  Kephritis:  Sometimes  follows  an  acute  attack  after  scarlet 
fever  or  exposure  to  cold — 3fai/  be  associated  with  (1)  the  large  white  kidney  ;  (2)  the 
red  granular  kidney — Symptoms  of  the  disease  ivith  the  large  white  kidney — Character 
of  the  wine — Albumen  occasionally  absent  in  confirmed  cases — Conclusions  to  be  drawn 
from  a  microscopic  examination  of  the  urine — Small  red  granular  kidney  rare  in  early 
life — Symptoms  and  morbid  appearances — -Cardio-vascular  changes — Lardaceous  or 
wary  kidney — Nature  and  causes — State  of  the  urine  in — Treatment  of  chronic  Bright'' s 
disease  in  the  different  varieties  of  the  affection. 

Chronic  desquamative  nephritis  is  a  very  rare  disease  in  chil- 
dren ;  it  may  be  the  consequence  of  an  acute  attack  after  scarlet 
fever,  or  exposure  to  cold,  but  in  by  far  the  greater  number  of  in- 
stances it  creeps  on  slowly,  and  belongs  to  adult  life.  The  course 
it  follows  and  the  symptoms  it  presents  in  children,  are  in  all  re- 
spects like  the  same  disease  in  the  adult.  If  the  acute  stage  does 
not  pass  away  completely,  and  any  inflammation  remains  behind, 
the  urinary  tubules  become  plugged  with  a  fibrinous  or  exudative 
material,  which  interrupts  the  circulation  through  the  gland,  and 
by  favoring  a  state  of  habitual  congestion,  renders  the  chances  of 
recovery  less  promising. 

After  an  attack  of  acute  Bright's  disease  (acute  desquamative 
nephritis),  when  the  constitutional  symptoms  have  improved,  and 
the  urine  remains  persistently  albuminous,  the  patient  is  exposed 
to  a  return  of  the  disorder  from  cold,  or  errors  in  diet,  renew^ing 
renal  congestion,  and  paving  the  way  for  incurable  degeneration. 
This  chronic  form  of  disease  may  be  associated  with  (1)  the  large 
white  kidney  ;  (2)  the  red  gramdar  kidney. 

It  appears  that  we  may  have  disease  of  the  kidnej's  commencing 
in  (1)  the  epithelial  lining  of  the  tubules;  (2)  m  the  fibrous  tissue; 
(3)  in  the  bloodvessels.  The  symptoms  and  morl)id  appearances 
are  characteristic  of  each  varietj^  to  a  great  extent,  and  ought  to 
be  carefully  studied  in  their  clinical  history  and  pathological  bear- 
ings. When  the  urinary  tubules  are  inflamed  and  irritated  by  the 
passage  of  a  specific  poison  through  them,  as  in  scarlet  fever,  they 
take  on  an  excess  of  cell  growth,  and,  as  exudation  proceeds  from 
the  congested  vessels,  the  kidney  increases  in  volume,  and  becomes 
large  and  smooth.  The  capsule  peels  oft'  readily  {large  white 
kidney).     If  the  disease  is  not  arrested,  or  cured,  the  morbid  altera- 


DISEASES   OF   THE   KIDNEYS   AND   URINARY   ORGANS.  265 

tions  continue,  and  the  miscliief  extends  to  the  intertubular  strnc- 
ture,  at  the  same  time  the  growth  of  tibruid  tissue  begins,  which 
may  end  in  contraction  and  granulation.  The  kidneys  are  reduced 
in  size  to  one-half,  especially  in  the  cortical  part,  and  the  surface 
instead  of  being  smooth  is  irregular  and  granulated.  They  are 
firm  and  fibrous,  and  the  capsule  thickened  and  adherent.  The 
depressions  and  granulations  are  produced  by  the  contraction  of 
the  fibrous  tissue  between  the  tubes  {gramdar  kidney — cirrhosis  of 
the  kidney). 

The  large  white  kidney  is  the  sequel  of  an  acute  attack  of 
nephritis,  particularly  after  scarlet  fever,  or  exposure  to  cold.  The 
dropsy  and  oedema,  if  present  during  any  time  of  the  acute  affec- 
tion, pass  off  more  or  less  completely,  leaving  the  state  of  the  urine 
to  tell  the  mischief  that  has  been  inflicted  upon  the  renal  organs. 
The  albuminuria  may  continue  for  months,  or  even  years,  before 
symptoms  of  degeneration  ensue ;  or,  indeed,  at  a  time  when  the 
general  health  is  in  no  way  deranged.  This,  however,  will  greatly 
depend  on  the  amount  of  albumen  in  the  urine ;  if  there  is  only  a 
mere  cloudiness  or  opalescence  in  the  secretion,  the  health  may  be 
unimpaired,  and  the  patient  perform  the  usual  duties  of  life  with- 
out suflering  any  inconvenience,  but  a  copious  precipitate  cannot 
continue  very  long  without  the  liability  of  a  return  of  dropsy  and 
inflammatory  complications.  The  disease  sometimes  commences 
as  a  chronic  disorder. 

The  general  symptoms  of  chronic  disease  with  a  large  white  kidney 
when  pronounced,  are  a  pale  and  pasty  face,  and  dropsy.  There 
is  loss  of  appetite  and  nausea,  and  the  bowels  and  stomach  are 
easily  deranged,  diarrhoea  and  vomiting  being  ver}'-  common.  In 
the  case  of  a  girl  under  my  care  in  1876,  the  profuse  albuminuria 
was  attended  on  three  or  four  occasions  with  severe  epistaxis, 
preceded  hj  frontal  headache.  Troublesome  cough,  from  conges- 
tion of  the  lungs  and  bronchial  irritation,  often  prove  extremely 
inveterate,  whilst  pericarditis,  and  serous  efi'usion  into  one  or  both 
pleural  sacs  is  not  uncommon.  Cerebral  symptoms  from  ursemia, 
and  haemorrhages  and  extravasations  of  blood,  more  especially 
belong  to  the  granular  form  of  the  complaint. 

The  urine  is  generally  pale  and  of  normal  specific  gravity  ;  as 
the  disease  proceeds,  a  microscopical  examination  detects  granular 
and  hyaline  casts.  The  variability  in  the  amount  of  albumen  in 
the  urine  from  time  to  time  is  just  one  of  those  circumstances 


266  DISEASES   OF   CHILDEEJiT. 

which  requires  especial  notice  and  attention.  The  patient,  to 
whom  I  have  alluded,  presented  a  good  example  of  this  when  the 
chronic  stage  was  established.  There  were  days  when  the  albu- 
men was  so  small  in  quantity  that  the  urine  revealed  on  careful 
examination  a  mere  trace,  and  I  had  my  doubts  whether  it  was 
present  at  all;  but  when  the  urine  was  allowed  to  stand  a  few 
hours,  after  carefully  employing  the  usual  tests,  its  presence  could 
invariably  be  verified.  I  can  only  connect  this  temporary  decrease 
of  albumen  to  some  mysterious  process  of  digestion.*  In  many 
cases  of  albuminuria  the  albumen  is  present  in  the  urine  chiefly, 
indeed,  in  many  cases  solely,  during  the  period  of  digestion  ;  just 
as  in  some  cases  of  diabetes  the  sugar  is  found  in  the  urine  mainly, 
and  sometimes  only,  during  digestion.! 

A  case  of  albuminuria  is  described  in  an  infant  seven  weeks  old. 
It  was  born  healthy,  but  soon  after  birth  suffered  from  constant 
vomiting.  There  was  no  history  of  scarlatina  or  measles,  and  no 
evidence  of  disease  in  the  thorax  or  abdomen  ;  indeed,  the  child 
lay  listlessl}^  in  any  position  in  which  it  was  placed,  and  appar- 
ently suft'ered  no  pain  whatever.  The  urine  was  "almost  like 
pure  water,  and  containing  suflicient  albumen  to  make  a  deposit 
of  some  height  in  the  test-tube."  Emaciation  followed,  and  death 
took  place  at  the  end  of  a  month.  As  the  kidneys  only  presented 
some  spots  of  congestion,  the  ease  was  considered  as  one  of  albu- 
minuria from  imperfect  digestion  and  assimilation  of  the  albumi- 
nous constituents  of  the  food.:};  In  other  cases  albumen  is  never 
present  in  the  urine  except  after  severe  exercise.  The  question 
maj',  however,  be  asked :  Is  albumen  in  such  a  case  as  this  ever 
entirely  absent  from  the  urine?  Dr.  Roberts  relates  the  case  of 
a  girl,  ?et.  8,  who  came  under  his  care  in  April,  1864.  She  had 
general  anasarca  after  scarlet  fever  four  months  previously.  There 
was  excessive  pallor,  shortness  of  breath,  and  a  puffy,  pasty  face. 
The  urine  was  scanty  and  high-colored,  but  not  a  trace  of  albumen 
or  tube-cast  could  be  found.  She  died  four  weeks  after  admission. 
On  a  post-mortem  examination,  "the  kidneys  were  good  examples 
of  the  'smooth,  white'  Bright's  kidney."     They  were  slightly  en- 

*  Temporary  albuminuria  may  arise  from  indigestible  articles  of  food,  as  some  kinds 
of  diec-se,  shellfish,  crabs,  cockles,  mussels,  etc.  Nervous  excitement  and  mental  emo- 
tion will  also  give  rise  to  it. — Dr.  Basham,  On  Dropsy,  186G,  p.  306. 

t  See  the  remarks  on  Intermittent  Albuminuria,  p.  253. 

X  "Albuminuria  in  a  child  seven  weeks  old,"  by  G.  F.  Helm,  B.A.,  F.R.C.S. ;  Lan- 
cet, Jan.  18th,  1868,  p.  8o. 


DISEASES   or   THE   KIDNEYS   AND    URINARY   ORGANS.  267 

larged,  and  the  capsule  peeled  off  readily.  The  surface  was  de- 
pressed here  and  there,  and  atro[»hy  had  commenced.* 

There  are  some  points  worth  considering  here  in  reference  to 
the  microscopical  character  of  the  urine.  In  the  earliest  stages  it 
is  scarcely  altered,  being,  as  we  have  before  mentioned,  of  normal 
color  and  specific  gravity,  but  more  or  less  albuminous.  When 
death  occurs  before  fatty  casts  and  cells  are  detected,  the  kidneys 
are  in  the  first  stage  of  degeneration  {large  white  smooth).  When 
small  hyaline  and  oily  casts  and  cells  appear  in  the  urine,  there  is 
a  process  of  atrophy  {fatty  degeneration).  When  granular  and  large 
hyaline  casts  appear,  there  is  a  further  contraction  of  the  kidney, 
or  the  disease  is  in  the  third  stage  {granular  degeneration). 

After  death  the  kidneys  are  found :  1.  Large,  white,  and  smooth. 
2.  The  same  appearance,  with  yellowish  opaque  specks  on  the  sur- 
face (granular  fat  kidney),  or  large  white  kidney,  with  fatty  de- 
generation. 3.  Atrophy  of  the  cortical  portion,  with  an  uneven 
granular  surface  (Johnson). 

The  small  red  granidar  kidney  so  far  belongs  to  advancing  years 
as  to  be  hardly  worth  noticing  under  the  diseases  of  early  life. 
It  is  a  chronic  and  insidious  disease  from  the  comrnencement,  and 
although  associated  with  the  gouty  diathesis  more  particularly, 
no  cause  can  be  assigned  in  a  lars-e  number  of  cases.  It  holds  no 
relationship  to  tubercle  whatever.  Dr.  Dickinson  has  seen  the 
disease  in  a  girl  of  5.  He  mentions  another  case  of  a  girl  under 
the  late  Dr.  Hillier  who  died  at  the  age  of  10,  and  one  under  Dr. 
Ogle,  at  St.  George's  Hospital,  of  a  boy,  who  died  at  11,  "with 
granular  degeneration  traceable  to  scarlatina."  Dr.  Dickinson  had 
two  fatal  cases  under  his  own  care  at  the  respective  ages  of  12  and 
14.t  The  disease  has  succeeded  to  scarlatina  contracted  many 
years  previously.  A  case  is  related  by  Barthels:};  of  a  girl  who  at 
10  years  of  age  had  ague,  measles,  and  scarlet  fever,  but  no  dropsy. 
At  18,  after  being  in  good  health  for  eight  years,  she  became 
aft'ected  with  albuminuric  retinitis ;  there  was  albumen,  with  small 
hyaline  casts  in  the  urine,  and  hypertrophy  of  the  left  ventricle. 
Maddenino;  headache  and  obstinate  vomitins^  succeeded  to  dimin- 
ished  urinary  secretion.     She  became  completely  blind,  and  h  xd 

*  On  Urinary  and  Renal  Diseases,  p.  408. 
f  Part  2,  Alburninnria,  p.  376. 

X  Cyclopaedia  of  the  Practice  of  Medicine,  by  Dr.  H.  von  Ziemssen,  Diseases  of  the 
Kidney,  vol.  xv,  p.  429. 


268  DISEASES    OF    CHILDREN". 

five  convulsions  of  an  epileptic  character  in  one  day.  To  these 
symptoms  succeeded  twitchings  of  the  muscles,  profuse  diarrhoea, 
and  death  from  exhaustion.  After  death  the  kidneys  were  found 
atrophied,  and  the  surfoce  mottled  and  covered  with  shallow  de- 
pressions; the  substance  of  the  organs  was  tough;  renal  arteries 
large ;  there  was  purulent  peritonitis  and  ulceration  of  the  mucous 
membrane  at  the  lower  end  of  the  ileum;  the  brain  was  pale  and 
firm;  the  left  ventricle  of  the  heart  was  hypertrophied. 

The  kidney  in  this  disease  is  much  reduced  in  weight,  the  sur- 
face is  rough  and  irregular,  and  the  capsule  so  thickened  that  it 
cannot  be  torn  off  the  surface  beneath  without  removing  some  of 
the  tissue.  Some  of  the  urinary  tubules  are  denuded  of  epithelium, 
and  others  contain  fibrinous  deposit.  The  urine,  in  granular  dis- 
ease of  the  kidney,  contains  a  small  quantity  of  albumen,  and  is 
copious  and  of  low  specific  gravity  ;  epithelial,  granular,  and  hya- 
line casts  are  found  under  the  microscope. 

Dropsy  is  almost  certainlj^  absent,  but  there  may  be  transient 
puffiness  of  the  eyes  and  ankles.  We  often  find  d_yspnoea  on  exer- 
tion from  osdema  of  the  pulmonary  tissue  or  cardiac  change  ;  and 
in  these  cases  the  face  is  sallow  rather  than  white. 

With  these  changes  the  heart  becomes  hypertrophied,  and  the 
arteries  thickened.  Simple  cardiac  hypertrophy  is  a  common  ac- 
corapanimeut  o^  granular  disease  of  the  kidney  ;  the  morbid  matters, 
not  readily  passing  through  the  capillaries,  raise  the  blood  pressure 
in  the  arteries,  and,  an  obstruction  thus  being  created  in  the  blood 
flow,  the  left  ventricle  hj'pertrophies.  For  a  long  time  there  may 
be  no  signs  present  except  accentuation  of  the  aortic  second  sound 
or  reduplication,  but  not  necessarily  any  murmur,  unless  the  valves 
are  diseased.  Atheromatous  change  has  been  found  in  the  mitral 
valve  and  aorta,  associated  with  granular  fibrosis  of  the  kidney  at 
the  age  of  six.*  The  muscular  coat  of  the  small  arteries  under- 
goes thickening,  and  even  degenerative  changes.  The  sphygmo- 
graph  affords  ample  evidence  of  this  in  the  characteristic  tracing, 
and  the  finger  placed  on  the  pulse  detects  tension  and  hardness. 
This  increased  effort  on  the  part  of  the  heart  and  systemic  arteries, 
causes  both  to  become  h^-pertrophied.  As  the  heart  increases  in 
power  the  vessels  lose  their  elasticity  and  become  brittle,  whilst 
the  force  with  which  the  blood  is  driven  through  their  channels, 
frequentlj'  leads  to  rupture  and  extravasations.     The  researches  of 

*  Dickinson,  op.  cit.,  p.  412. 


DISEASES   OF   THE   KIDNEYS   AND   URINARY   ORGANS.  2G9 

Sir  William  Gull  and  Dr.  Sutton  are  in  the  direction  of  proving, 
that  the  view  advanced  by  Dr.  Johnson  is  unsupported  by  their 
experiments  and  investigations  ;  they  consider  that  blood  charged 
with  urinary  excreta  does  not  satisfactorily  explain  the  cause  of 
hypertrophy  of  the  heart,  and  the  arterial  changes  in  the  muscu- 
lar coat  of  the  smaller  vessels.  This  change  in  the  minute  arteries 
is  due  to  the  formation  of  a  "  hyaline-fibroid  "  substance  in  the  in- 
tertubular  parts  of  the  kidney,  '-and  that,  in  fact,  the  muscular 
coat  is  often  variously  atrophied."  The  cardio-vascular  changes 
are  not  consecutive  to  the  renal  mischief;  they  may  be  independent 
of  it,  and  the  contracted  granular  kidney  forms  only  part  of  a 
general  morbid  condition.  These  observers  admit  the  frequent 
association  between  hypertrophy  of  the  heart  and  renal  degenera- 
tion, but  at  the  same  time  they  consider  that  this  is  no  proof  of 
any  relation  between  them  of  cause  and  effect.  The  large  white 
kidney,  the  granular  contracted  kidney,  and  the  lardaceous  kid- 
ney have  been  found  when  the  heart  was  free  from  hypertrophy. 
For  further  information  on  the  subject  I  refer  the  reader  to  the 
paper  of  Sir  William  Gull  and  Dr.  Sutton.* 

The  next  form  is  that  known  as  the  lardaceous  or  waxy  kidney. 
It  has  also  received  the  name  of  amyloid  kidney.  A  waxlike 
material  is  found  infiltrating  the  kidney,  commencing  in  the  mus- 
cular coat  of  the  minute  arteries ;  this  imparts  to  the  kidney  a 
smooth  and  anaemic  look.  When  the  disease  is  far  advanced,  the 
gland  loses  all  its  smoothness,  and  becomes  shrunken,  uneven,  and 
puckered.  On  incising  the  surface,  the  natural  structure  is  seen 
to  be  much  wasted,  the  cortex  is  bloodless,  and  the  cones  red, 
whilst  the  whole  organ  is  much  more  tough  and  hard.  This  dis- 
ease is  secondary  and  constitutional,  not  local.  It  consists  pri- 
marily in  a  change  in  the  composition  of  the  blood,  and  secondarily 
in  the  walls  of  the  arteries,  as  well  as  all  the  organs  of  the  body 
which  they  supply. f 

The  striking  peculiarity  of  the  morbid  deposit  is  a  deep  brown- 
reddish  color,  which  it  assumes  on  the  addition  of  a  weak  solution 
of  iodine. 

The  causes  of  the  disease  are  chronic  suppuration  from  caries  or 

*  Med.-Chir.  Trans.,  vol.  Iv,  1872,  Chronic  Bright's  Disease  with  Contracted 
Kidney  (Arterio-capillary  Fibrosis). 

t  See  Chapter  XX,  On  Diseases  of  the  Liver, — Lardaceous  or  Amyloid  Disease 
of  the  Liver. 


270  DISEASES   OF   CHILDREN. 

necrosis  of  bones,  scrofulous  abscesses,  phthisis,  chronic  bedsores, 
S3"philis,  etc. 

The  disease  is  essentially  chronic  and  most  common  in  males. 
It  is  most  frequent  between  20  and  80.  Dr.  Dickinson  has  seen  it 
in  a  child  of  5,  and  he  alludes  to  the  case  of  a  boy  2}  years  old, 
under  Dr.  Gee,  who  died  from  chronic  abscesses  in  the  thigh  and 
P3'femia.*  The  disease  is  recognized  during  life  b}^  a  worn  and 
cachectic  look  ;  by  the  copious  secretion  of  albuminous  urine  ;  and 
by  the  presence  of  oedema  and  dropsy.  The  urine  is  abundant  in 
the  early  stages,  but  as  the  complaint  advances  it  becomes  scanty, 
very  albuminous,  and  of  high  specific  gravity.  "  Cells  resembling 
those  of  pus  are  occasional!}'  found,  either  separate  or  aggregated 
round  a  cast.  The  tube-casts  are  usually  hyaline,  and  do  not  yield 
a  brown  coloration  with  iodine.  Epithelial  casts  are  also  some- 
times seen."t  Thej-  are  sometimes  granular,  or  they  contain  fatty 
epithelium  (Green). 

Treatment  of  Chronic  Bright' s  Disease. — To  aim  at  a  cure  or  to 
give  relief  in  this  formidable  complaint,  we  must  bear  in  mind  the 
course  of  the  malady  and  its  tendency  towards  a  fatal  termination  ; 
for  in  so  doing  we  know  what  symptoms  to  expect,  and  how  best 
to  avert  or  relieve  them  when  they  threaten.  The  cause  having 
been  ascertained,  we  may  learn  how  to  approach  the  disease  in  its 
milder  forms  with  some  chance  of  success.  Is  it  the  sequel  of  an 
acute  attack,  or  a  chronic  insidious  disease  from  the  first  ?  Is  the 
constitution  fairly  good,  or  the  health  broken  down  ?  For  on  the 
issue  of  these  questions  our  opinion  may  be  in  a  great  measure 
guided.  In  one  case  the  tendenc}'  of  the  renal  changes  will  be  to 
cause  cerebral  trouble  in  the  form  of  chronic  headache,  confusion 
of  ideas,  and  convulsions  or  coma;  in  another  case  infiammatory 
complications  of  the  serous  cavities  ;  in  a  third  anasarca  or  dropsy  ; 
in  a  fourth  derangement  of  the  stomach  and  bowels  is  the  chief 
evidence  of  the  poisoned  blood ;  in  a  fifth  the  changes  fall  chiefly 
on  the  sj'stemic  vessels,  and  the  left  ventricle  of  the  heart,  pro- 
ducing for  a  time  no  other  indication  of  failing  health  than  stupor 
and  inactivity,  nausea  and  capricious  appetite,  or  occasional  epis- 
taxis  or  heematuria. 

If  the  chronic  disease  has  succeeded  to  the  acute  variety  of  the 
affection,  as  after  scarlet  fever  or  exposure  to  cold,  great  care  is 

*  Dickinson,  part  2,  Albuminuria,  1877,  p.  491. 

f  On  Urinary  and  Renal  Dise;ises,  by  Dr.  Roberts,  1876,  p.  491. 


DISEASES   OF   THE   KIDNEYS   AND    URINARY   ORGANS.  271 

required  not  to  submit  the  patient  to  changes  of  temperature,  or 
to  an  irregular  diet,  as  acute  renal  congestion  is  rekindled  on 
slight  provocation.  If  there  is  chronic  disease  of  any  bone  or  joint, 
and  the  albuminuria  appears  to  be  dependent  on  these  affections, 
then  the  source  of  such  irritation  should  be  removed  if  possible 
before  the  patient's  strength  is  worn  out,  and  the  renal  degen- 
eration is  too  ftir  advanced. 

If  there  is  local  pain  to  any  extent  across  the  loins  the  patient 
should  be  put  to  bed  and  a  linseed  poultice  applied.  If  the  urine 
is  turbid  and  contains  renal  blood-casts,  it  is  advisable  to  make 
the  child  lie  on  the  abdomen  to  lessen  the  renal  congestion,  and  to 
give  diluents  and  fluid  diet.  In  one  case  immediate  relief  followed 
the  adoption  of  this  simple  method  of  treatment. 

When  the  patient  is  well  enough  to  be  out  of  doors  he  should 
be  warmly  clothed  with  flannel  next  the  skin,  and  the  greatest 
care  be  taken  to  avoid  cold.  A  residence  at  the  seaside  is  to  be 
recommended,  and  moderate  exercise  may  be  taken  if  the  disease 
is  not  so  far  advanced  as  to  prevent  it. 

All  treatment  will  be  futile  without  the  most  rigid  attention 
to  diet,  and  this  should  consist  chiefly  of  milk,  or  milk  and  water, 
if  there  is  much  albumen  in  the  urine,  and  renal  congestion  is 
present  to  any  extent.  Animal  food  should  be  prohibited  under 
these  circumstances,  for  if  indulged  in  it  will  increase  arterial  ten- 
sion, and  derange  the  digestive  functions.  This  is  not  borne  out 
by  the  experience  of  some  writers,  who  consider  that  animal  food 
should  be  given  as  soon  as  the  stomach  will  bear  it.  "  It  is  a 
most  remarkable  fact  that  the  albumen  in  the  urine  decreases  by 
the  use  of  animal  food,  and  increases  again  under  a  vegetahle  diet."* 
But  this  testimony  is  quite  at  variance  with  my  experience,  as  the 
case  of  E.  S ,  related  at  p.  257,  very  strikingly  proves. 

All  stimulants  should  be  prohibited,  as  they  are  apt  to  produce 
deleterious  consequences.  Children  do  not  require  them  in  health, 
and  there  is  no  disorder  in  which  they  would  prove  more  injurious. 

If  anffimia  is  a  leading  feature  of  the  complaint,  the  liquor  ferri 
perchloridi  is  a  good  haematic,  and  a  safe  diuretic  at  the  same  time. 
When  the  urine  is  deficient  in  quantity,  and  there  is  any  anasarca 
from  renal  inadequacy,  the  efficacy  of  the  tincture  of  the  per- 
chloride  is  well  spoken  of  in  combination  with  the  liquor  ammonite 

*  Basham,  On  Dropsy,  1866,  p.  217. 


272  DISEASES    OF    CHILDREIS". 

acetatis.  "  It  is  as  an  aramonio-chloride  kept  in  solution  by  acetic 
acid  that  its  beneficial  influence  becomes  most  apparent.  It  is  a 
very  simple  preparation  ;  a  few  drops  of  the  tincture,  according  to 
the  age  of  the  patient,  are  added  to  a  drachm  of  the  liquor  am- 
monice  acetatis,  previously  acidulated  with  acetic  acid."*  Another 
writer  on  this  subject  also  testifies  to  the  same  eflfect.  "I  have 
frequently  combined  with  each  dose  of  the  perchloride  of  iron  ten 
grains  of  the  hydrochlorate  of  ammonia;  and  I  believe  that  this 
ammonio-chloride  of  iron  is  a  useful'preparation."'f' 

If  there  is  any  renal  congestion,  the  addition  of  small  doses  of 
perchloride  of  mercury  to  the  liquor  ferri  perchloridi,  as  previously 
referred  to  under  the  acute  aflection,  will  be  advisable.  The  syrup 
of  the  iodide  of  iron,  the  syrup  of  the  phosphate  of  iron,  or  steel 
wine,  in  combination  with  cod-liver  oil,  are  useful  preparations  in 
strumous  subjects,  and  may  be  taken  advantageouslj^  for  weeks 
together.  However  important  it  may  be  to  improve  the  quality 
of  the  blood  in  chronic  Bright's  disease  by  the  exhibition  of  ferru- 
ginous preparations,  they  cause  in  many  instances  so  much  head- 
ache and  constipation,  that  they  cannot  be  given  alone  for  any 
length  of  time  ;  if  the  headache  is  dependent  on  congestion  rather 
than  on  anemia,  they  must  be  set  aside  for  other  remedies.  The 
bowels  ought  to  act  once  every  day  at  least. 

Sometimes  the  mineral  acids — phosphoric,  nitric,  or  hydrochloric 
— are  useful  where  the  loss  of  albumen  is  excessive,  and  there  is 
atonic  dyspepsia.  Gallic  acid  seems  to  be  ineffectual  in  lessening 
the  drain  of  albumen. 

Dr.  Lauder  Brunton  found  that  strychnia  in  doses  of  gr.  oVth 
stopped  the  albumen  in  a  case  of  chronic  and  intermittent  albumi- 
nuria, but  caused  sickness  and  headache  ;  in  the  same  case  pan- 
creatic enmlsion  stopped  it  at  first,  but  afterwards  it  became  worse 
than  ever;  quinine  and  sulphuric  acid  doubled  the  quantity  in 
twenty-four  hours.  But  the  same  authority  speaks  in  the  highest 
terms  of  arsenic,  which  acts  "  upon  the  secreting  structures  of  the 
kidney  .  .  .  and  a2:)pears  also  to  possess  a  special  affinity  for 
epithelial  structures."  He  gave  Liq.  Fowleri  Ti^iij  at  mealtimes 
and  the  albumen  disappeared,  reappearing  when  the  arsenic  was 
discontinued,  and  again  arresting  the  albumen  when  the  remedy 
was  resumed.    The  case  in  question  was  supposed  by  Dr.  Brunton  to 

*  Basham,  On  Dropsy,  1866,  p.  218. 

t  Lectures  on  Briglit's  Disease,  by  G.  Johnson,  M.D.,  1S73,  p.  138. 


DISEASES   OP   THE   KIDNEYS   AND    URINARY   ORGANS.  273 

be  clue  to  "  imperfect  digestion  of  albuminous  substances,  which 
were  absorbed  from  the  intestine,  and  excreted  in  the  urine  in 
much  the  same  way  as  wliite  of  egg  would  have  been  if  the  person 
had  swallowed  several  raw  eggs  at  once."* 

For  any  dropsical  condition  that  may  exist,  a  dose  of  the  com- 
pound jalap  powder,  witli  a  little  bitartrate  of  potash,  is  a  good 
and  quickly  acting  aperient,  which  may  be  given  once  or  twice  a 
week  in  a  little  tea  or  plain  water,  early  in  the  morning,  but  even 
this  aperient  must  be  employed  with  due  consideration  to  the  gen- 
eral strength. 

If  anasarcous  effusion  is  great,  it  may  be  necessary  to  puncture 
the  extremities.  The  ordinary  practice  is  to  make  one  or  two 
punctures  through  the  subcutaneous  tissue  on  the  dorsum  of  the 
foot  or  calf  of  the  leg,  from  half  an  inch  to  an  inch  in  length,  and 
then  to  wrap  the  limb  in  hot  moist  ilannel.  I  have  repeatedly 
made  a  small  puncture  either  on  the  dorsum  of  the  foot  or  over 
one  or  both  ankles,  and  then  wrapped  the  limb  in  dry  flannel, 
changing  it  as  often  as  it  becomes  very  wet.  I  have  never  seen 
any  local  irritation  or  erysipelas  follow  this  plan,  though  the  drain 
of  fluid  in  some  cases  has  been  enormous.  Dr.  Southey  has  re- 
corded the  notes  of  a  case  of  parenchj'matous  nephritis,  in  which 
tlie  anasarca  was  combated  by  drainage-tubes  and  small  silver 
canulas.  The  advantages  claimed  were,  that  one  puncture  in 
each  limb  was  suflficient,  and  that  sores  and  erysipelas  were  not  so 
likely  to  ensue ;  the  canula  could  be  kept  in  the  same  opening 
without  inconvenience  for  forty-eight  hours,  and  when  the  instru- 
ment was  withdrawn  the  orifice  closed  at  once.  Above  all  the 
patient  is  kept  dry.  Several  pints  of  dropsical  effusion  may  thus 
be  safely  and  painlessly  drained  away  in  the  course  of  one  day.f 
Dr.  Southey  found  the  same  plan  equally  advantagfeous  in  drawing 
away  pleuritic  effusions  | 

Diuretics  are  sometimes  serviceable  to  assist  in  the  removal  of 
dropsical  effusions.  In  some  forms  of  the  disease  diuresis  is  pro- 
fuse enough  to  contraindicate  their  use.  They  are  infinitely  less 
valuable  than  purgatives,  which  relieve  the  portal  circulation  and 
intestinal  veins,  by  inducing  watery  secretion  from  the  bowels.  I 
have  a  great  preference  for  digitalis,  with  acetate  or  citrate  of 
potash,  when  an  alkali  is  not  objectionable. 

*  Arsenic  in  Albuminuria,  Practitioner,  June,  1877,  p.  432. 

t  Clin.  Trans.,  vol.  x,  1877.  t  Ibid.,  vol.  xii,  1879. 

18 


274  DISEASES   OF   CHILDREN. 

BroncTiial  and  dyspeptic  symptoms  require  uo  special  considera- 
tion ;  they  must  be  treated  according  to  the  circumstances  of  each 
particular  case,  remembering  tliat  the  strength  of  the  patient  is  to 
be  carefully  husbanded,  and  that  mercury  and  antimony,  if  occa- 
sionally required,  are  seldom  necessary. 

If  ursemic  symptoms  threaten,  the  action  of  the  skin  and  kid- 
neys must  be  encouraged.  The  poisoned  and  watery  state  of  the 
blood  will  seldom  admit  of  venesection  or  any  kind  of  depletion. 

An  occasional  warm  bath  is  an  excellent  diaphoretic,  by  pro- 
moting the  action  of  the  skin,  and  increasing  the  secretion  of  urine 
at  the  same  time.  The  skin  becomes  supple  under  its  use,  and  a 
general  amelioration  in  the  patient's  condition  takes  place.  I  have 
known  headache  relieved  when  the  temperature  of  the  bath  has 
not  exceeded  98°,  but  if  much  higher,  and  there  is  no  free  sweat- 
ing, headache,  capillary  engorgement  of  the  face,  and  other  dis- 
tressing symptoms  may  ensue. 

Finally,  we  may  repeat  that  warm  clothing,  thick  boots,  care 
against  cold,  especially  in  the  evenings,  and  a  seaside  residence 
ought  to  be  rigidly  enforced. 


CHAPTER    'X^IY  {continued). 

DISEASES   OF    THE    KIDNEYS    AND   URINARY   ORGAN^. 

Dysueia — Eenal  Concretions  and  Calculi — Lithiasis— Symptoms  of  Stone 
IN  THE  Kidney  and  Bladder — Oxaluria — Hematuria — Tubercle  of  the 
Kidney — Cancer  of  the  Kidney — Hydronephrosis  —  Incontinence  of 
Urine — Diabetes  mellitus — Diabetes  insipidus — Acute  Cystitis — Causes 
— Symptoms  and  treatment. 

Dysuria — Renal  Concretions  and  Calculi. — Calculous  disorders 
are  very  common  in  early  life,  from  the  liability  of  the  digestive 
functions  when  deranged  to  cause  irritation  in  the  urinary  passages. 
The  imperfect  assimilation  of  the  nitrogenous  principles  of  food 
checks  their  downward  metamorphosis  to  urea,  so  that  a  quantity 
of  intermediate  products  are  formed ;  these  products  are  either 
insoluble,  or,  at  least,  irritating  to  the  geni to-urinary  organs. 

Liihiasis  is  recognized  by  pain  and  weight  about  the  loins,  and 
^difficulty  in  voiding  urine,  which  is  scanty  and  high-colored;  it 
•becomes  turbid  on  cooling,  and  has  a  strong  sickly  odor.     The 


DISEASEvS   OF   THE   KIDNEYS   AND   UEIXAEY   ORGANS.  275 

commonest  form  of  gravel  consists  of  urate  of  ammonia,  or  free 
uric  acid,  which  falls  to  the  bottom  of  the  vessel  on  standing  like 
brickdust.  The  digestive  functions  are  deranged,  the  tongue  being 
furred,  the  appetite  excessive,  and  the  bowels  costive.  The  child 
is  restless  and  feverish  at  night,  and  loses  energy  and  activity. 
The  white  or  pink  tinge  of  the  urates  depends  upon  the  amount 
of  coloring  matter  in  the  urine.  "  In  young  children  the  '  milky 
urine,'  which  alarms  motliers,  is  due  to  a  deposit  of  peculiarly 
white  urates."*t  The  pink  or  brickdust  deposit,  only  visible 
after  the  urine  has  cooled,  and  readily  dissolved  by  heat,  consists 
of  the  amorphous  urate  of  ammonia  colored  with  purpurin.  The 
milky  sediment,  which  exists  as  a  deposit  before  the  urine  has 
cooled,  is  formed  of  the  crystals  of  urate  of  soda. 

When  a  careful  section  of  the  kidneys  is  made,  yellowish  or 
brownish  striee  may  be  seen  running  towards  the  base  of  the 
pyramids.  This  appears  to  be  a  post-mortem  change  arising  from 
the  precipitation  of  the  urates  into  the  uriniferous  tubes.:):  When 
it  occurs  during  life  it  may  prove  the  commencement  of  those 
changes  which  lead  to  gravel  or  calculus,  blocking  up  the  urinif- 
erous tubes,  and  finally  causing  them  to  become  impervious,  or 
the  concretions  escape  into  the  pelvis  of  the  kidney,  where  they 
may  be  seen  in  large  numbers  after  death. 

The  symptoms  of  stone  in  the  kidney,  or  of  the  descent  of  a 
calculus  from  the  kidney  to  the  bladder,  are  less  marked  in  chil- 
dren than  in  adults.  There  is  febrile  disturbance,  and  pain  and 
difficulty  in  passing  water,  with  localized  pain  and  tenderness 
over  one  loin.  In  severe  cases,  there  is  faintness  and  vomiting, 
and  the  skin  is  bedewed  with  a  clammy  sweat.  Uric  acid  calculi 
have  been  seen  in  the  pelvis  of  the  kidney  of  an  infant.  The 
occurrence  of  colic  in  children  of  three  or  four  years  old  is  often 
attended  with  uric  acid  gravel  (West).§    It  must  always  be  borne 

*  Guide  to  the  Examination  of  the  Urine,  by  Dr.  Wickham  Legg,  2d  edition,  1872, 
p.  48. 

t  "  In  the  urine  of  children  it  is  veTy  frequently  met  with  in  the  form  of  small 
spherical  globules  very  like  the  crystals  of  carbonate  of  lime  from  horses'  ui'ine ;  and 
these  sometimes  occur  in  the  adult." — Urine  and  Urinary  Deposits,  by  Dr.  Beale,  1861, 
p.  275. 

X  "In  infants  dying  within  forty-eight  hours  of  their  birth,  such  striae  are  almost 
invariably  found  (Virchow);  they  have  also  been  found  in  still-born  infants,  which 
have  never  respired  (Hoogeweg  and  Martin)." — On  Urinary  and  Renal  Diseases,  by  Dr. 
Koberts,  3d  edition,  1876,  p.  477. 

I  "  Dr.  Debout  d'Estrees  gives  an  account  of  a  child  at  Contrexeville,  born  of  gouty 


276  DISEASES    OF    CHILDREX. 

in  mind  that  it  is  most  difficult  to  elicit  symptoms  of  localized 
pain  in  children. 

The  treatment  of  dysuria  and  uric  acid  gravely  when  severe,  con- 
sists in  the  eniploj'ment  of  warm  baths  at  bedtime,  which  relieve 
the  pain  of  micturition  and  encourage  diaphoresis.  If  there  is 
reason  to  think  from  the  local  and  recurrent  pain  that  a  concre- 
tion has  formed  in  the  kidney,  hot  poultices  to  the  loins  will  be 
advisable.  The  bowels  must  be  kept  fully  open,  and  for  this  pur- 
pose there  is  nothing  better  than  a  full  dose  of  castor  oil.  After 
this  a  mixture  of  liquor  potassse  and  tincture  of  hyoscyamus  will 
lessen  the  acidity  of  the  urine,  and  promote  its  free  discharge. 
The  diet  should  be  sparing  and  unstimulating,  and  should  consist 
of  milk  and  water,  barley-water,  and  thin  arrowroot.  Xo  animal 
food  should  be  given  whatever  till  the  urine  has  assumed  a  healthy 
state,  and  pain  and  irritation  have  passed  away.  The  waters  of 
Carlsbad  and  Vichy  are  very  useful. 

In  children,  calculi  and  wnnary  sediments  usually  consist  of 
urates,  hence  tlie  alkaline  carbonates  are  verj^  serviceable,  and 
they  may  be  persevered  with  to  great  advantage.  Children  who 
have  had  rheumatism  sometimes  suiffer  from  uric  acid  in  the 
urine,  and  in  such  cases  the  diathesis  will  require  careful  atten- 
tion. 

When  a  s-tone  has  formed,  the  child  must  be  handed  over  to  the 
surgeon.  The  symjjtoms  of  stone  in  the  bladder  in  children  are  the 
same  as  in  the  adu,lt — frequent  desire  to  pass  water,  which  is 
voided  with,  painful  efiorts,  and  is  sometimes  mixed  with  blood ; 
occasional  stoppage  of  the  stream,  and  a  sore  and  elongated  pre- 
puce from  the- child's  hands  being  constantly  applied  to  it.  Pro- 
lapsus ani,  accompanied  with  marked  dysuria,  is  often  the  first 
symptom  of  calculuas  in  children. 

Calculi,  though  frequent  in  boys,  are  very  rarely  found  in  female 
children.  Hence,  when  morbid  vesical  symptoms  occur  in  little 
girls,  the  probability  of  the?  presence  of  a  stone  in  the  bladder 
must  not  be  overlooked  on  account  of  its  rarity.     In  the  autumn 

parents,  which  had  real  nephritic  fits  at  a  fortnight  old.  The  mother,  a  young  woman, 
twenty-.six  years  old,  who  had  been  suffering  from  uric  gravel  for  four  years,  had, 
during  her  pregnancy,  three  fits  of  nephritic  colic ;  nevertheless,  the  child  was  born  in 
due  time  and  in  good  condition,  but  a  fortnight  after  its  birth  it  had  real  nephritic 
fits,  vomiting,  writhing,  and  complaining  chiefly  when  the  loins  were  touched.  The 
fits  ended  by  the  emission  of  rather  thick  sand.  TJiey  returned  every  six  weeks." — 
A  Few  Words  on  the  Causes  of  Gravel,  Practitioner,  June,  1877. 


DISEASES   OF   THE   KIDNEYS   AND   URINABY   ORGANS.  277 

of  1877  a  girl,  nine  years  of  age,  came  under  my  care  in  the 
Samaritan  Hospital.  Her  mother  stated  that  she  had  been  sub- 
ject since  birth  to  incontinence  of  urine,  and  for  more  than  six 
months  before  admission  she  suflered  from  dysuria,  with  constant 
desire  to  pass  water.  On  the  day  of  admission  the  labia  were 
swollen,  and  the  clitoris  was  large  and  tender.  A  few  excres- 
cences, neither  vascular  nor  painful,  existed  around  the  meatus 
urinarius.  The  urine  contained  a  trace  of  albumen,  and  there 
was  a  scanty  deposit  of  pus-cells.  Suspecting  the  presence  of  a 
calculus,  I  asked  my  colleague,  Mr.  Alban  Doran,  to  sound  the 
patient  under  chloroform.  He  discovered  a  large  stone,  and  two 
days  later  removed  it  through  the  urethra,  which  he  enlarged  by 
means  of  the  dilator,  invented  by  the  late  Professor  Simon,  of 
Heidelberg.  The  stone  weighed  2.V  drachms,  and  consisted  of  a 
nucleus  of  uric  acid,  coated  with  oxalate  of  lime.  The  patient 
was  enabled  to  retain  her  urine  and  to  pass  it  at  will  the  follow- 
ing day.     She  made  a  good  and  rapid  recovery. 

Within  a  month  after  this  patient  was  discharged,  a  delicate 
girl  of  ten  was  admitted,  also  suffering  from  incontinence  of  urine 
and  occasional  dysuria.  There  was  a  distinct  history  of  calculus 
in  the  family,  her  maternal  uncle  having  been  operated  on  for 
stone  when  a  youth.  A  sound  was  introduced  into  the  bladder 
under  chloroform,  but  no  calculus  could  be  detected.  The  mucous 
membrane  of  the  bladder  was  rough  at  one  or  two  points.  The 
ino-uinal  and  the  whole  line  of  iliac  and  lumbar  glands  were  much 
enlarged,  but  the  abdominal  walls  were  flattened,  and  none  of  the 
solid  viscera  had  increased  in  size.  On  examining  her  urine  two 
da^'s  after  the  sounding  it  presented  manj^  of  the  qualities  it  did 
on  admission ;  it  was  very  acid,  and  deposited  a  large  amount  of 
mucus.  Under  the  microscope,  a  great  number  of  crystals  of 
oxalate  of  lime  were  detected.  She  recovered  completely  under 
rest  and  antistrumous  remedies. 

Dr.  W.  Eoberts*  and  others  have  s^iown  that  although  oxalaria 
is  most  frequent  in  nervous  and  debilitated  young  people,  it  is  not 
accompanied  with  definite  symptoms,  since  in  many  cases  it  may 
exist  to  such  an  extent  as  to  produce  the  characteristic  mulberry 
calculus,  without  any  constitutional  symptoms,  until  the  stone  has 
mechanically  caused  vesical  irritation. 

Hcematuria  or  haemorrhage  from  the  kidneys  in  children  may  be 

*  Uriiia.17  and  Eenal  Diseases,  1876. 


278  DISEASES    OF    CHILDEEX. 

met  with  in  tuberculosis,  scarlatina,  purpura,  and  some  other  dis- 
eases in  Avhich  the  blood  has  undergone  changes  in  its  composition. 
A  case  of  acute  hsematuria  is  recorded  in  a  girl  of  nine,  in  which 
sudden  hferaorrhage  followed  the  disappearance  of  severe  pustular 
eczema  on  the  face  and  body,  of  two  years'  duration  *  I  have 
given  details  of  a  very  interestiug  case  of  ''  Paroxysmal  or  inter- 
mittent heematuria  in  a  young  child,  following  supposed  injury. "f 
The  treatment  must  be  in  accordance  with  the  disease  which  has 
originated  the  s^-mptoms.  Gallic  acid  in  iive-grain  doses,  three 
times  a  day,  will  be  found  beneficial,  and  if  there  is  anpemia,  the 
tincture  of  the  perchloride  of  iron  is  a  good  styptic  and  diuretic 
at  the  same  time.  Quinine  may  be  sometimes  prescribed  with 
advantage.  If  there  is  any  evidences  of  renal  congestion,  rest  in 
bed  and  a  milk  diet  will  be  necessary. 

Tubercle  of  the  kidney  is  seen  in  cases  of  general  tuberculosis,  one 
kidney  being  generally  afl:ected.  The  organ  is  increased  in  size, 
and  converted  into  a  soft,  cheesy,  yellow  mass.  Anj^  treatment  is 
unsatisfactory. 

Cancer  of  the  kidney  is  a  rare  disease,  and  when  present,  is  of  the 
medullary  character. :J:  I  have  had  no  experience  of  the  affection, 
but  authors  describe  the  symptoms  as  beginning  with  pain  in  the 
region  of  the  kidney,  frequent  micturition,  and  the  presence  of 
blood  and  albumen  in  the  urine.  It  is  extremely  doubtful  whether 
cancer-cells  have  been  seen  in  the  urine.  "  The  most  important 
symptom  is  a  generally  uneven,  nodulated,  immovable  tumor, 
sometimes  as  large  as  a  child's  head,  reaching  from  the  false  ribs 
to  the  crest  of  the  ilium,  and  inwards  to  the  vertebral  colunm, 
and  occupying  a  considerable  part  of  the  abdominal  cavity." 
(Steiner.j§  The  children  become  cachectic  and  sallow,  and  finally 
die  exhausted.  Mr.  Spencer  Wells  has  recorded  a  most  interesting 
case  of  soft  cancer  of  the  right  kidney  in  a  girl  only  four  years  of 
age.  "  The  diagnosis  in  this  case  was  made  without  much  difii- 
culty,  although  the  urine  was  quite  normal.  The  growth  was 
extremely  rapid,  hardly  six  months  from  its  commencement  to  its 
fatal  terminatiou,  when  the  diseased  mass  weighed  between  16 

*  Brit.'Med.  Journ.,  1878,  vol.  ii,  p.  877.  f  TJie  Lancet,  vol.  ii,  1880,  p.  336. 

%  "In  the  Children's  Hospital  at  Prague  in  100,000  cases  it  was  only  seen  four 
times." — Steiner  on  Diseases  of  Children,  by  Lawson  Tait,  187-4,  p.  279. 

^  "  In  16  children  its  average  weight  was  81  lbs. ;  the  smallest  was  1  lb.  9  oz.,  and 
the  largest  31  lbs." — On  Uriiw.ry  and  Reno.1  Diseases,  by  Dr.  "W.  Huberts,  1876,  p.  523. 


DISEASES   OF   THE   KIDNEYS   AND    URIXARY   ORGANS.  279 

and  17  lbs.  The  tumor  occupied  the  whole  of  the  right  side  of  the 
abdomen,  bulging  backwards  in  the  right  loin.  It  was  uniformly 
elastic,  but  no  fluctuation  could  be  detected.  The  intestines  were 
pushed  downwards,  and  to  the  left  side.  The  rapid  growth,  and 
the  absence  of  fluctuation,  were,  of  course,  strongly  against  the 
opinion  that  the  tumor  was  ovarian  ;  while  the  rarity  of  ovarian 
disease  in  young  children,  and  the  comparative  frequency  of  renal 
encephaloid,  led  to  a  diagnosis  which  was  confirmed  by  a  puncture 
with  a  fine  exploring  needle.  A  few  drops  of  reddish  serum  were 
obtained,  containing  nucleated  cells  of  various  size  and  shape.  I 
sent  the  child  home,  with  a  note  to  Dr.  Williamson,  of  ISTantwich, 
expressing  my  opinion  that  the  tumor  was  a  mass  of  soft  cancer,- 
and  that  the  right  kidney  was  the  most  probable  seat  of  the  dis- 
ease. This  proved  to  be  correct.  Dr.  Williamson  sent  me  the 
specimen,  and  I  exhibited  it  at  the  Pathological  Society  in  Decem- 
ber, 1862.*  The  whole  kidney  was  infiltrated  with  encephaloid. 
Although  so  enormously  enlarged,  the  shape  of  a  normal  kidney 
was  distinctly  preserved.  Its  surface  was  soft  and  elastic,  in  some 
spots  giving  a  sense  of  deepseated  fluctuation,  but  no  cyst  was 
found,  nor  were  there  any  marks  of  suppuration  or  haemorrhage. 
Coils  of  small  intestine  adhered  to  its  inner  and  under  surface. 
The  ureter  was  completely  occluded  by  the  pressure  of  the  tumor. 
The  left  kidney  was  quite  healthy.  Thus  the  normal  condition 
of  the  urine  was  explained.  The  diseased  kidney  added  nothing 
to  the  contents  of  the  bladder,  and  the  healthy  kidney  supplied 
only  normal  urine."t 

Hydronephrosis — Dropsy  of  the  Kidney. — This  disorder  is  caused 
by  an  obstruction  to  the  escape  of  urine  from  the  kidney.  The 
pelvis  of  the  kidney  becomes  dilated  into  a  pouch  or  bag,  and  the 
renal  substance  atrophied  or  absorbed.  Sometimes  it  is  divided  into 
smaller  compartments  or  cavities.  The  tumor  may  attain  enor- 
mous dimensions,  and  fill  the  abdomen  as  a  soft  fluctuating  mass. 
In  women  it  has  been  mistaken  for  an  ovarian  cyst,  and  tapped 
under  that  impression.     One  or  both  kidneys  may  be  afl:ected.:{: 

"Of  52  cases  collected  by  me  the  hydronephrosis  was  confined 
to  one  kidney  in  32  instances,  and  afi:ected  both  (double  hydrone- 
phrosis) in  20  cases.     When  the  hydronephrosis  was  single  the 

*  Trans.  Path.  Soc,  vol.  xiv,  p.  179. 
t  Diseases  of  the  Ovaries,  1872,  p.  203. 
X  See  Chap.  XXVI. 


280  DISEASES   or  CHILDREN. 

right  side  was  more  frequently  aifected  than  tlie  left  (19  right  and 
13  leftj.''^*"  Of  these  52  cases  "there  existed  congenital  malforma- 
tion in  20  cases,  affecting  the  kidneys,  the  ureter,  and  the  renal 
artery In  13  out  of  the  20  congenital  cases  the  hydrone- 
phrosis was  double,  that  is,  it  affected  both  kidneys.  Two  of  these 
perished  still-born,  one  lived  six  hours,  one  thirty,  and  one  thirty- 
six,  whilst  one  died  twenty  days,  and  another  between  three  and 
four  months,  after  birth."t 

The  contents  of  these  cysts  consists  of  watery  urine,  uric  acid, 
and  the  earthy  salts,  but  blood,  pus,  and  epithelium  may  be  also 
present.  Death  may  occur  suddenlj'-  from  uremia.  In  some  cases 
of  congenital  hydronephrosis  urea  is  absent.  A  very  interesting 
case  is  recorded  by  Mr.  Henrj'  Morris  to  prove  that  urine  is  freely 
secreted  during  intrauterine  life,  and  that  a  considerable  quantity 
which  the  bladder  and  ureters  cannot  hold  is  passed  into  the  sac 
of  the  amnion,  in  which  the  child  floats.  Urea  appears  to  be  in 
very  small  proportion  (5  in  lOOOj.J 

Hydronephrosis  is  found  to  be  caused  by  the  impaction  of  a  stone 
or  calculus  in  the  ureter,  which  causes  inflammation  and  contrac- 
tion ;  an  imperforate  urethra  is  another  cause.  A  pelvic  growth, 
by  compressing  the  ureter,  may  prevent  the  escape  of  the  urine, 
lu  some  obscure  cases  no  mechanical  cause  can  be  ascertained  to 
account  for  the  condition. 

The  symptoms  depend  on  the  size  of  the  tumor  and  the  pressure 
it  exerts  on  surrounding  organs. '  The  usual  situation  of  the  tumor 
is  in  the  lumbar  region,  extending  forward  to  the  umbilicus  and 
downwards  to  the  iliac  region.  The  tumor  is  soft  and  fluctuating ; 
it  is  sometimes  felt  distinctly  lobulated,  and  if  of  large  size  there 
is  dyspnoea,  and  the  child  cannot  lie  down  without  difliculty. 
The  colon  generally  lies  in  front  of  the  tumor,  "There  is  one 
peculiarity  which  is  pathognomonic  when  present,  namely,  the 
sudden  diminution  or  disappearance  of  the  swelling  coincidently 
with  the  sudden  discharge  of  a  large  quantity  of  urine.  This  sign 
is  not  always  available,  but  it  is  sufiiciently  frequently  met  with 
to  give  it  an  important  diagnostic  value. "§ 

When  the  symptoms  arise  from  the  impaction  of  a  calculus, 

*  Renal  and  Urinary  Diseases,  by  Dr.  Roberts,  3d  edit.,  1876,  p.  487. 

t  Ibid.,  p.  490. 

X  Case  of  Congenital  Hydronephrogis,  Royal  Med.-Cliir.  See.,  May  13th,  1876. 

g  On  Urinary  and  Renal  Diseases,  by  Dr.  Roberts,  1876,  p.  497. 


DISEASES   OF   THE   KIDNEYS   AND   URINARY   ORGANS.  281 

attacks  of  nephritic  colic  and  vomiting  are  not  uncommon,  with 
pus  and  even  blood  in  the  urine.  If  both  kidneys  are  affected, 
then  the  elimination  of  urea  is  imperfect,  and  symptoms  of  urfemia 
may  be  looked  for.  Should  the  disease  be  caused  by  a  renal  cal- 
culus it  may  be  dislodged,  and,  the  sac  emptying  itself,  the  symp- 
toms pass  away,  the  sac  shrivelling  up  and  causing  no  further 
trouble.  Peritonitis,  septicaemia,  or  suppuration  in  the  tumor,  fol- 
lowed by  hectic,  may  ensue.  Impaired  health  and  chronic  tuber- 
culosis have  also  followed. 

Treatment. — A  milk  and  flaid  diet  is  preferable  to  much  animal 
food,  as  it  is  important  to  keep  the  urine  free  and  to  avoid  the 
accumulation  of  fecal  matter  in  the  bowels.  When  there  is  con- 
stipation a  warm-water  enema,  or  a  mild  non-irritating  aperient, 
will  be  called  for.  In  the  case  of  a  little  girl  under  Dr.  Roberts's 
care,  friction  and  shampooing  the  tumor  resulted  in  the  escape  of 
a  large  quantity  of  urine,  and  the  swelling  subsided.  Other  eases 
are  recorded  where  the  tumor  has  suddenly  disappeared  after  a 
profuse  discharge  of  urine  through  the  ureter  and  bladder.  If 
this  does  not  occur,  and  the  patient's  rest  is  broken  from  pain  and 
want  of  sleep,  tapping  may  be  had  recourse  to  as  a  means  of 
temporary  relief.  In  October,  1879,  a  girl  seven  years  of  age  was 
admitted  under  my  care  into  the  Dorset  Street  Branch  of  the 
Samaritan  Hospital  suffering  from  abdominal  tumor,  which  had 
been  known  to  exist  since  she  was  two  years  old.  The  case  was 
seen  by  my  colleagues  and  variously  diagnosed  as  hj'datid,  ovarian, 
and  renal.  Mr.  Knowsley  Thornton,  holding  the  latter  opinion, 
advised  and  performed  exploratory  and  antiseptic  tapping,  and 
drew  off  six  and  a  half  pints  of  slightly  albuminous  urine.  The 
cyst  refilled,  and,  the  diagnosis  being  now  certain,  Mr.  Thornton 
removed  the  cyst  by  laparotomy  on  January  2d,  1880,  securing 
the  renal  vessels  with  fine  earbolized  silk,  and  using  all  details  of 
Lister's  method.  Some  congestion  of  the  other  kidney,  with  h^ema- 
turia,  followed  the  operation,  but  passed  off  in  a  few  hours,  and 
the  child  recovered  rapidly,  and  four  months  afterwards  was  in 
jDcrfect  health.  The  cyst  was  shown  as  a  fresh  specimen  at  the 
Pathological  Society,  January  6th,  the  child  at  a  meeting  of  the 
Royal  Medical  and  Chirurgical  Society,  March  9th,  1880,  when 
nephrectomy  was  under  discussion,  and  full  details  have  been  pub- 
lished by  Mr.  Thornton  jointly  with  myself.* 

*  The  Lancet,  vol.  i,  1880,  p.  870. 


282  DISEASES   OF   CHILDREN. 

Enuresis  (incontinence  of  urine). — This  common  disease  in  chil- 
dren is  generally  difficult  to  cure,  and  the  closest  investigation 
frequently  fails  to  discover  the  true  cause.  It  is  met  with  in  the 
progress  of  disease  of  the  bladder  and  brain,  and  from  deficient 
power  in  the  tone  of  the  bladder  and  sphincter,  in  weakly  and 
strumous  subjects,  "  We  can  sometimes  trace  the  affection  to 
spinal  irritation ;  and  the  worst  case  of  the  disease  I  ever  saw  was 
in  a  girl  affected  with  diseased  spine."*  It  may  originate  from 
gastro-intestinal  disorder,  ascarides  in  the  rectum,  and  an  excess 
of  uric  acid  in  the  urine.  When  these  sources  of  irritation  are 
removed  the  patient  gets  well.  But  incontinence  of  urine,  among 
children  in  too  many  instances,  appears  to  arise  from  no  mechan- 
ical or  inflammatory  condition  of  the  bladder  or  kidney,  and  from 
no  unhealthy  state  of  the  urine.  We  know  that  the  child  wets 
the  bed,  but  neither  the  parents  nor  the  physician  can  always 
assign  any  reason  for  it.  A  long  prepuce  would  seem  to  be  a  fre- 
quent cause.  A  very  obstinate  case  under  my  care,  which  had 
resisted  all  drugs,  was  cured  on  its  removal.  Children  who  are 
put  to  bed  without  emptjnng  the  bladder,  often  wet  the  bed  at 
night,  and  when  the  habit  is  once  established,  it  is  difficult  to 
overcome.  In  some  children  the  absence  of  control  over  the  blad- 
der occurs  only  at  night,  and  in  others  during  the  daytime  also  ; 
in  some  cases  there  is  almost  a  constant  dribbling,  and  the  child 
is  wet  and  excoriated,  v^'hilst  in  other  cases  the  desire  to  pass 
water  is  very  frequent,  and  he  cannot  hold  it  for  a  moment  when 
once  the  desire  to  pass  it  has  commenced.  Boys  suffer  far  more 
frequently  than  girls.  It  may  be  again  urged  that  the  condition 
of  the  urine  may  increase  its  irritating  qualities,  especially  acid 
conditions.  In  such  cases,  a  comparatively  small  quantity  of 
urine  in  the  bladder  may  excite  reflexly  the  relaxation  of  the 
sphincters. 

Incontinence  of  urine  commonly  depends  upon  an  abnormal  con- 
dition of  the  bladder  centres  situated  in  the  lumbar  portion  of  the 
cord. 

In  normal  micturition,  the  sensation  of  fulness  in  the  bladder 
is  received  by  the  centre  in  the  cord,  until  it  excites  an  efl:erent 
impulse  to  the  sphincter,  which  relaxes  and  permits  the  contents 
of  the  bladder  to  escape.  In  early  infancy  this  does  not  excite 
consciousness ;  then  the  micturition  is  involuntarj^,  and  purely 

*  Plolmes's  Surgical  Treatment  of  Children's  Diseases,  1868,  p.  581. 


DIPEASES   OF   THE   KIDNEYS   AXD    URIXAEY   ORGANS.  283 

reflex.  About  the  period  of  the  completion  of  the  first  dentition, 
or  even  earlier,  a  child  ordinarily  becomes  conscious  of  the  call  to 
void  urine,  and  intimates  the  desire  to  its  nurse.  The  relations  of 
the  call  to  consciousness  have  become  established.  These  relations 
never  become  lost  again  ordinarily,  except  in  very  advanced  life, 
or  in  disease  of  the  spinal  cord.  Under  other  circumstances  the 
relations  of  this  call  to  consciousness  do  not  become  perfectly 
established.  In  the  majority  of  cases  of  nocturnal  incontinence, 
during  the  period  of  wakefulness,  the  little  patient  is  conscious  of 
the  call,  but  during  sleep  the  reflex  action  goes  on  without  excit- 
ing consciousness.  'In  more  aggravated  cases  the  call  does  not 
excite  the  attention,  and  the  incontinence  occurs  during  the  wak- 
ing state,  as  well  as  during  sleep. 

Prognosis. — This  is  hopeful,  for  as  the  child  grows  older  he 
gains  strength.  Incontinence  of  urine  usually  ceases  at  puberty, 
when  the  spinal  centres  become  perfectly  developed.  The  disease 
is  never  fatal. 

Treatment. — From  what  has  been  written  concerning  the  causes 
of  enuresis,  the  treatment  will  have  to  be  adopted  accordingly. 
The  patient  should  lie  on  a  hard  bed,  and  strict  attention  be  paid 
to  hygienic  rules.  As  bedtime  approaches,  the  quantity  of  fluid 
should  be  limited,  and  two  or  three  hours  after  falling  asleep  the 
child  should  be  awakened  to  pass  water,  and  the  same  thing  should 
be  repeated  during  the  night,  that  the  bladder  may  not  get  too 
full.  lie  should  be  prevented  from  lying  on  his  back,  and  for  this 
purpose  a  handkerchief  tied  round  the  waist,  with  a  knot  over  the 
spine. 

If  the  urine  is  high-colored  and  there  are  urates,  it  must  be  put 
into  a  healthy  state,  but  if  it  is  clear  and  throws  down  no  deposit, 
the  extract  of  belladonna  (gr.  \  to  gr.  J)  three  times  a  day  is  a 
drug  we  ought  to  employ.  "It  appears  generally  admitted  that 
of  all  specilic  means  the  administration  of  belladonna  is  the  most 
eflfectual,  and  such  is  certainly  my  experience.  I  begin  with  |^th 
of  a  grain  of  the  extract  three  times  a  day,  or  a  smaller  quantity 
in  very  young  children,  and  gradually  increase  the  quantity  until 
the  fauces  and  the  pupil  become  affected.  If  the  enuresis  is  not  ma- 
terially relieved  by  the  time  tlie  fauces  become  dry  and  the  pupil 
enlarged,  I  leave  oflF  the  drug  ;  but  if  there  is  a  material  improve- 
ment, a  few  days'  perseverance  will  usually  cure  the  disease  for  a 
time.     I  believe  that  it  is  liable  to  recur,  as  I  have  seen  several 


284  DISEASES   OF   CHrLDREN". 

cases  of  relapse.  Thej  are,  however,  under  the  immediate  control 
of  the  drug,  and  are,  therefore,  of  no  very  serious  consequence."* 

In  belladonna  poisoning  there  is  paralytic  retention  of  urine,  con- 
sequently in  these  cases  of  hyperfesthesia  of  the  bladder  centres 
belladonna  is  useful. t  In  those  cases  where  no  abnormal  source  of 
irritation  can  be  discovered  it  is  well  to  give  belladonna.  In  many 
cases  this  drug  will  effect  a  cure,  but  it  should  be  given  in  full 
doses,  and  all  3'oung  creatures,  including  human  beings,  bear  com- 
paratively larger  doses  of  this  agent  than  are  required  in  the  case 
of  adults.  "  I  have  been  obliged  to  give  as  much  as  5iss.  or  even 
5ij  of  the  tincture  before  success  was  attained.":]:  In  many  cases 
it  is  well  to  add  bromide  of  potassium  to  the  belladonna. 

If  the  condition  seems  to  depend  on  debility,  the  tincture  of  the 
perchloride  of  iron,  with  or  without  strychnia,  will  be  found  of 
service — five  minims  in  a  little  water  three  times  a  da}^  has  often 
proved  of  great  benefit  in  my  hands.  The  mineral  acids,  too,  are 
sometimes  serviceable.  Cold  sponging  to  the  loins  and  lower  part 
of  the  back  in  the  early  morning  are  useful  measures,  and  in  very 
obstinate  cases  a  blister  to  the  sacrum.  "  Another  local  applica- 
tion, which  is  very  energetic,  and  in  obstinate  cases  ought  certainly 
to  be  employed,  is  the  cauterization  of  the  neck  of  the  bladder. 
Either  the  stick-caustic  should  be  used,  or  a  solution  of  ten  grains 
or  even  more  to  the  ounce.  I  prefer  the  former.  But  it  is  a  very 
painful  application  and  not  free  from  danger,  and  should  never  be 
employed  till  after  the  failure  of  general  treatment."!  I  have  ap- 
plied to  the  urethra,  a  solution  of  nitrate  of  silver  (9j  ad  oj),  with 
very  encouraging  results.  The  patient,  a  nervous  timid  girl,  ten 
years  of  age,  had  suft'ered  from  incontinence  of  urine  from  birth, 
and  the  treatment  hitherto  employed  had  been  unsuccessful.  The 
incontinence  took  place  during  the  night,  as  well  as  the  day,  and 
the  mother  said  "  her  child's  clothes  were  alwaj's  wet."  I  used  a 
small  uterine  sound,  and  twisted  round  the  top  of  it  a  piece  of 
cotton-wool,  well  saturated  with  the  solution.  This  was  passed 
along  the  urethra  to  the  neck  of  the  bladder,  and  then  quickly 
withdrawn.  The  application  caused  no  pain  at  the  time,  nor  any 
subsequent  inconvenience.     At  the  end  of  a  week,  the  patient  had 

*  Holmes,  op.  cit.,  p.  585. 

t  A  Treatise  on  Tlierapentics,  by  II.  C.  Wood,  M.D.,  1876,  p.  232. 

X  A  Guide  to  Therapeutics,  by  R.  Farquharson,  M.D.,  1877,  p   223. 

§  Holmes,  op.  cit.,  p.  584. 


DISEASES   OF   THE   KIDNEYS   AND   URINARY   ORGANS.  285 

only  wetted  the  bed  once ;  at  the  termination  of  a  fortnight,  twice  ; 
and  on  both  these  occasions  the  incontinence  was  nocturnah  I 
should  state  that  as  the  urine  was  high-coloi-ed  and  rather  acid,  I 
prescribed  a  mixture  of  belladonna  and  bicarbonate  of  potash,  but 
the  good  effects  were,  I  believe,  largely  attributable  to  the  caus- 
tic application,  as  the  child  had  been  under  the  care  of  several 
medical  men,  who  had,  no  doubt,  eniplo^-ed  the  usual  remedies. 

In  some  cases  of  imperfect  development  of  the  cerebro-spinal 
system,  this  incontinence  of  urine  is  best  treated  by  strychnia,  a 
well-known  stimulant  to  the  spinal  centres ;  in  other  cases  there 
is  a  hyperfesthesia  of  the  bladder  centres  in  the  cord,  and  then  a 
sedative  like  bromide  of  potassium  is  indicated  ;  in  some  cases, 
other  different  sensations  than  these  of  a  full  bladder  are  received 
by  this  centre,  and  under  what  may  be  called  a  misconception,  the 
efferent  impulse  is  sent  off"  to  the  sphincter  to  relax,  and  the  con- 
tents of  the  bladder  escape.  In  such  case,  careful  search  for  every 
possible  source  of  such  irritation  must  be  instituted,  and,  if  pos- 
sible, be  found  and  removed.  Without  that,  all  treatment  is 
futile. 

According  to  Dr.  Herbert  Tibbits,  incontinence  of  urine  in 
children  has  yielded  to  faradization  after  every  other  sort  of  treat- 
ment had  failed.  "  One  sponge  should  be  applied  over  the  symphy- 
sis pubis,  and  the  other  to  the  sacrum  and  perinseum  alternately."* 

Sometimes  enuresis  arises  from  a  long  prepuce,  and  when  this 
is  the  case  there  is  nothing  to  do  but  to  remove  it.  A  boy,  aged 
six  years,  came  under  my  care  in  1871,  suffering  from  incontinence, 
which  was  perpetually  troubling  him  during  the  day,  but  not  at 
night.  The  prepuce  was  very  long,  and  the  child  perpetually  put 
his  hands  to  it,  which  kept  up  the  irritation.  The  tincture  of  the 
perchloride  of  iron  was  given  without  relief.  Hydrate  of  chloral, 
in  five-grain  doses  every  night  at  bedtime,  caused  temporary  im- 
provement, but  he  soon  grew  w^orse  than  ever.  Large  doses  of 
belladonna  kept  the  disease  in  check  for  three  weeks,  and  then  the 
symptoms  returned  with  their  former  severity.  The  removal  of 
the  prepuce  completely  cured  him. 

A  chronic  case  of  incontinence  of  urine  is  recorded  by  Mr. 
Teevan,  in  which  a  perfect  cure  was  brought  about  by  an  opera- 
tion.!    ^  boy,  12  years  of  age,  had  suffered  from  nocturnal  incon- 

*  A  Handbook  of  Medical  and  Surgical  Elecrticitv,  1877,  p.  215. 
f  Practitioner,  October  1st,  1876. 


286  DISEASES   OF   CHILDREN. 

tinence  from  birth,  and  all  medical  treatment,  iucliiding  iron  and 
belladonna,  had  been  unavailing.  On  the  11th  of  February,  1876, 
when  Mr,  Teevan  saw  him  first,  the  urethral  orifice  was  "not  much 
bigger  than  a  pin-hole,"  and  there  was,  in  addition,  "a  small  blind 
internal  fistula  situated  just  above  the  sphincter."  The  sphincter 
was  divided,  and  the  floor  of  the  meatus  externus  incised.  Six 
weeks  afterwards  the  cure  was  complete  and  permanent. 

Acute  cystitis  is  sometimes  met  with  in  children  either  from 
injury,  or  the  irritation  of  stone  in  the  bladder.  It  is  also  said  to 
arise  from  cold,  and  to  occur  during  the  course  of  febrile  affections. 
The  mucous  membrane  of  the  bladder  is  injected  and  swollen,  and 
pours  out  considerable  secretion.  In  the  chronic  form,  mucus  and 
pus  are  freely  poured  out.  The  sj^mptoms  are  straining  in  passing 
w^ater,  followed  b}"  a  few  drops  sometimes  mixed  with  blood  ; 
pain  over  the  pubis  and  weight  in  the  perinseum.  In  a  ease  of 
simple  acute  cj-stitis  which  came  under  my  notice  in  Xovember, 
1876,  the  desire  to  pass  urine  was  frequent,  and  very  painful.  The 
patient  was  a  girl  ten  years  of  age,  and  no  cause  could  be  dis- 
covered to  produce  it.  There  was  no  indication  of  stone  or  other 
mechanical  cause.  The  urine  was  neveralbuminous,  but  frequently 
high-colored  and  turbid,  and  this  was  the  onl}''  explanation  that 
could  be  offered.  Under  the  influence  of  rest  in  bed,  and  a  milk 
diet,  with  a  mixture  of  citrate  of  potash,  the  symptoms  passed  off 
in  about  a  fortnight,  the  urine  never  becoming  ammouiacal  or 
alkaline. 

Treatment. — This  consists  in  confinement  to  bed,  and  the  em- 
ployment of  warm  hip-baths  at  bedtime,  if  micturition  is  frequent 
and  painful.  A  linseed-meal  poultice  should  be  employed  over  the 
loins,  or  lower  part  of  the  abdomen,  if  there  is  much  pain.  A 
demulcent  mixture  of  mucilage  and  liquor  potasste,  with  or  with- 
out opium,*  is  useful  to  allay  pain  and  irritation  which  the  acid 
urine  excites.  In  some  cases,  tincture  of  belladonna  with  citrate 
of  potash  is  even  more  eflicacious.  As  a  mild  and  efficient  purga- 
tive there  is  nothing  better  than  castor  oil.  The  diet  must  be 
simple  and  no  stimulants  of  anjj-  kind  should  be  given.     ]\Iilk  and 

*  Formula  45  : 

R.    Liquor,  potass., 5J 

Liquor,  opii  sed., llp^'iij 

Mucilag., 5SS. 

Mist,  caniph.  ad .^iv. — M. 

A  tablespoonful  every  four  hours  for  a  child  of  eight  or  ten  years  old. 


DISEASES   OF   THE   KIDNEYS   AND   URINARY   ORGANS.  287 

water,  or  milk  in  soda-water,  are  the  best  forms  of  nourishment. 
If  milk  is  strongly  objected  to,  then  weak  veal  or  chicken  broth, 
and  barley-water  must  be  substituted.  In  this  respect,  the  diet 
and  treatment  generally  are  closely  akin  to  that  recommended  for 
the  uric  acid  diathesis. 


CHAPTER    XXIV  {continued). 

DISEASES    OF    THE    KIDNEYS    AND    URINARY    ORGANS. 

Diabetes:  Varieties  of .  1.  Diabetes  mellitus  :  Sj/mptoms — Causes — Tests  for  sugar 
in  the  urine — Patholor/y— Prognosis — Treatment.  2.  Diabetes  insipidus,  or  Sim- 
ple Diuresis:  Symptoms — Causes — Pathology — Treatment. 

Diabetes  mellitus  is  recognized  by  a  large  increase  in  the 
urinary  secretion,  owing  to  the  presence  of  sugar.  The  complaint 
is  not  frequent  in  adults,  and  in  children  it  is  exceedingly  rare, 
particularly  under  five  years  of  age.  It  is  not  alluded  to  by  Tan- 
ner, or  Meigs  and  Pepper,  Vogel,  or  Lewis  Smith.  Dr.  West 
mentions  one  case  as  having  come  under  his  observation,  in  a  little 
girl  three  and  a  half  3^ears  of  age,  whose  brother  at  two  years,  and 
whose  sister  at  two  and  a  half  years,  died  of  the  same  disease.* 
Out  of  a  total  of  nearly  7C0  cases.  Dr.  Prout  only  saw  one  instance 
in  a  child  of  five,  and  about  a  dozen  cases  between  eight  and 
twenty  years  of  age,  four  of  whom  were  females. f  Dr.  W.  Rob- 
erts met  with  it  in  a  boy  of  three  years,  and  he  mentions  the 
singular  fact  that  as  many  as  ten  deaths  from  diabetes  under  the 
age  of  one  year  are  recorded  in  the  Registrar-General's  Report  for 
1851-1860.5: 

Symptoms. — These  are  gradual  in  their  onset,  the  disease  being 
generally  of  some  weeks',  or  even  mouths'  duration  before  it  is  dis- 
covered. Failing  strength  and  gradual  loss  of  flesh,  notwithstand- 
ing an  excessive  appetite,  excite  suspicion  that  the  patient  is  going 
wrong.  Then  the  frequent  calls  to  pass  urine  in  immoderate 
quantities,  and  the  insatiable  thirst  soon  clear  up  the  nature  of  the 
malady.  It  is  worthy  of  notice  that  there  may  be  urgent  thirst 
before  the  renal  secretion  is  increased.     The  urine  is  of  a  light 

*  West,  on  the  Diseases  of  Infancy  and  Childhood,  1859,  p.  655. 
t  Prout,  on  Stomach  and  Renal  Diseases,  1848,  5th  edit.,  p.  36. 
X  On  Urinary  and  Renal  Diseases,  1876,  p.  221. 


288  DISEASES    OF    CHILDREX. 

straw-color,  and  has  the  odor  of  new-mown  hay  ;  it  is  more  or  less 
saccharine  in  taste,  and  of  high  specific  gravity,  reaching  1030  to 
1050,  or  even  1060.  In  this  respect  it  differs  from  albuminous 
urine,  and  that  of  diabetes  insipidus.  It  should,  however,  be  borne 
in  mind  that  the  specific  gravity  of  saccharine  urine  may  be  low. 
Prout  mentions  a  case  where  it  was  as  low  as  1010,*  and  Dr.  W. 
Eoberts  says  it  may  sink  to  1015. f  There  appears  to  be  an  an- 
tagonism between  diabetes  and  gout,  the  latter  ceasing  on  the 
sujDervention  of  the  former  in  adults.;}: 

As  the  complaint  advances,  the  symptoms  increase  in  severity, 
the  thirst  becomes  greater,  and  the  appetite  is  excessive ;  the 
patient  rapidly  loses  flesh  and  strength  ;  the  skin  is  dry  and  harsh  ; 
the  tongue  clean  and  flabb3',or  red  and  aphthous ;  digestion  is  de- 
ranged,, and  pain  or  sinking  at  the  stomach  is  often  present,  with 
more  or  less  flatulence,  or  even  vomiting ;  the  bowels  are  consti- 
pated and  the  mind  is  dej^ressed.  In  some  cases  there  is  sweating 
at  this  stage,  and  even  attacks  of  diarrhoea.  Inflammatory  com- 
plications of  the  pleura  and  peritoneum  may  supervene,  and  later 
on  symptoms  of  pulmonary  phthisis,  with  diarrhoea  and  hectic. 
Phthisis  is  the  most  frequent  termination  according  to  Prout. 
The  urine  now  diminishes  in  quantit}^  the  legs  become  oedematous, 
and  death  usually  occurs  from  exhaustion.  In  some  cases  death 
takes  place  from  coma. 

Causes. — The  disease  appears  to  prevail  chiefly  in  families  that 
are  phthisical  or  epileptic.  Dr.  W.  Roberts  alludes  to  a  family  of 
eight  children  who  all  became  diabetic,  though  the  parents  were 
healthy ,§  and  instances  are  mentioned  in  which  it  has  appeared 
through  the  third  and  fourth  generations.  The  excitins;  causes 
are  probably  exposure  to  cold  and  damp,  drinking  large  quantities 
of  fluid  when  the  bodj^  is  heated,  excessive  use  of  saccharine  articles 
of  food,  febrile  diseases,  and  mental  emotion.  "  Glycosuria  has 
been  repeatedly  observed  in  cases  of  pneumonia,  whooping-cough, 
and  phthisis,  which  lead  to  deficient  oxygenation  of  the  blood."|| 
Some  disturbance  in  digestion  and  assimilation  apj^ears  capable  of 
originating  it;  the  kidneys  take  an  excessive  action  followed  by 
the  usual  symptoms. 

*  Front,  on  Stomach  and  Renal  Diseases,  1848,  5th  edit.,  p.  25. 

f  On  Urinary  and  Kenal  Diseases,  1876,  p.  226. 

X  Lectures  on  Diseases  of  the  Liver,  by  C.  Murcliison,  M.D.,  1877,  p.  559. 

§  Op.  cit.,  p.  223. 

II  Lectures  on  Diseases  of  the  Liver,  by  C.  Murchison,  M.D.,  1877,  p.  558. 


DISEASES   OF   THE   KIDNEYS   AND   URINARY   ORGANS.  289 

Diabetes  is  sometimes  of  traumatic  origin,  following  injury  to 
the  brain  or  spinal  cord. 

The  chief  tests  for  sugar  in  the  urine  are  three: 

1.  The  Copper  Test  (Trommer's  test). — Put  some  of  the  suspected 
urine  in  a  test-tube,  to  which  add  a  drop  or  two  of  a  solution  of 
sulphate  of  copper.  Liquor  potass?e  to  the  extent  of  half  the 
volume  of  urine  is  then  added,  and  the  mixture  boiled.  If  sugar 
is  present,  a  reddish  deposit  of  the  suboxide  of  copper  is  thrown 
down.  When  there  is  no  sugar,  the  precipitate  consists  of  black 
oxide  of  copper. 

Fehling^s  solution  is  a  more  delicate  test  than  the  preceding. 
Boil  a  small  quantity  of  the  solution  in  a  test-tube,  and  then  add  a 
few  drops  of  urine.  If  there  is  much  sugar  present,  a  yellowish- 
brown  precipitate  of  oxide  of  copper  will  be  thrown  down.  When 
no  change  results  from  boiling  an  equal  quantity  of  urine  and  the 
solution,  there  is  no  sugar  present.  Pellets  containing  the  constit- 
uents of  the  cupric  test,  introduced  by  Dr.  Pavy,  are  convenient, 
and  form  both  a  simple  and  reliable  test. 

2.  Moore's  Test. — An  equal  quantity  of  urine  is  to  be  boiled  with 
liquor  potasses  in  a  test-tube,  when,  if  sugar  be  present,  the  mix- 
ture will  assume  a  dark-brown  brandy-color.  There  is  some  objec- 
tion to  this  test,  as  the  same  proceeding  slightly  darkens  healthy 
urine.  "Again,  all  high-colored  urines  of  high  density  become 
darker  when  boiled  with  liquor  potassfe,  although  free  from  sugar, 
and  albuminous  urines,  even  when  not  high-colored,  darken  sen- 
sibly under  the  same  treatment."* 

3.  The  Fermentation  Test. — A  little  German  yeast  is  to  be  put  into 
a  test-tube,  and  then  filled  to  the  top  with  the  suspected  urine. 
The  tube  is  now  to  be  inverted  in  a  dish  or  saucer,  and  put  in  a 
warm  place,  or  in  a  temperature  of  80°.  The  urine  begins  to  fer- 
ment, and  carbonic  acid  gas  is  seen  collecting  at  the  top  of  the 
tube,  and  if  there  is  a  large  quantity  of  sugar,  all  the  urine  is 
driven  out  before  it.  According  to  Dr.  Roberts,  this  is  a  less 
sensitive  method  of  sugar-testing  than  Moore's  plan.f 

Another  plan  is  to  take  two  glasses  of  urine  ;  to  one,  add  Ger- 
man yeast,  and  put  both  aside  in  a  warm  place  for  twenty-four 
hours  ;  then  take  the  specific  gravity  of  each  ;  the  dift'erence  will 
indicate  the  number  of  grains  per  ounce. 

*  On  Urinary  and  Eenal  Diseases,  by  W.  Koberts,  M.D.,  1876,  p.  183. 

t  Op.  cit.,  p.  183. 

19 


290  DISEASES    OF   CHILDBEN. 

Pathology. — Claude  Bernard,  in  1848,  stated  that  sugar  was 
secreted  by  the  liver  in  health,  and  that  if  the  eighth  pair  of 
nerves  were  irritated  at  their  origin  in  the  fourth  ventricle,  an 
abnormal  quantity  of  sugar  is  produced  in  the  liver.  The  sugar  so 
formed  was  supposed  to  be  carried  to  the  heart  by  the  hepatic 
veins  and  vena  cava,  thence  it  was  conducted  to  the  lungs  by  the 
pulmonary  arteries,  and  combustion  taking  place,  the  sugar  was 
consumed.  Further  researches  have  tended  to  show  that  it  is 
glycogen,  not  sugar,  that  is  formed  in  the  liver  ;  but  glycogen  is 
a  product  so  readily  converted  into  sugar,  that  as  far  as  the 
pathology  of  diabetes  is  concerned,  the  distinction  is  not  impor- 
tant. 

When  the  sugar  formed  in  the  process  of  digestion  is  in  excess 
of  the  capacity  of  the  liver  to  dehydrate  into  glycogen,  then  it 
appears  in  the  urine.  Or  in  cases  where  oxj^genation  is  defective, 
and  the  sugar  found  in  the  liver  and  muscles  is  consequently  not 
burnt  off,  then  also  it  appears  in  the  urine.  We  therefore  get 
glycosuria  as  the  consequence  of  derangement  of  the  digestive  act, 
or  in  diseases  where  the  blood  is  imperfectly  oxygenized.  Fur- 
.ther,  "  whatever  quickens  the  circulation  of  the  blood  through  the 
liver,  particularly  in  the  hepatic  arteries,  favors  the  conversion  of 
glycogen  into  sug'ar,  possibly  by  increasing  the  amount  of  albu- 
minoid ferment ;  and,  accordingly,  whatever  paralyzes  the  vaso- 
motor nerves  of  the  hepatic  vessels,  either  directly  or  indirectly, 
dilates  these  vessels,  produces  an  increased  flow  of  blood  through 
them,  and  so  leads  to  diabetes."* 

Prognosis. — This  is  very  unfavorable,  the  disease  being  fatal  in 
the  greater  number  of  cases,  and  the  younger  the  child  the  greater 
is  the  fatality.  The  duration  of  the  disease  is  variable.  It  usu- 
ally lasts  from  one  to  three  years.  "  I  saw  a  case,  a  child  of  three 
years,  who  died  in  three  weeks.  Becquerel  mentions  the  case  of  a 
boy  of  nine  years  who  died  in  six  days."!  If  sugar  persists  in  the 
urine  when  the  patient  is  restricted  to  a  purely  animal  diet,  it  is 
of  evil  omen. 

Treatment. — This,  in  children,  is  based  on  the  treatment  found 
useful  in  diabetes  in  adults ;  it  mainly  consists  in  regulating  the 
diet,  so  as  to  prevent  the  accumulation  of  sugar  in  the  blood,  for 
on  this  depends  the  excessive  thirst,  the  inordinate  appetite,  and 

*  Lectures  on  Diseases  of  the  Liver,  by  C.  Murchison,  M.D.,  1877,  p.  558. 
t  Dr.  W.  Roberts  on  Urinary  and  Renal  Diseases,  1876,  p.  281. 


DISEASES   OF   THE   KIDNEYS   AND   URINARY   ORGANS.  291 

the  emaciation.  All  food,  therefore,  containing  sugar,  or  articles 
convertible  into  it,  should  be  avoided,  espjecially  bread  and  pota- 
toes, rice,  tapioca,  and  arrowroot — indeed,  all  matters  rich  in 
starch.  Some  vegetables,  as  turnips,  cabbage,  broccoli,  carrots, 
parsnips,  peas,  asparagus,  and  seakale,  must  be  avoided.  Endive, 
watercress,  lettuce,  and  celery,  may  be  taken.  Sweet  fruits,  as 
apples,  pears,  oranges,  and  currants,  fresh  or  preserved,  are  dele- 
terious. Animal  food  is  chiefly  to  be  relied  on ;  bacon  and  ham, 
fish  of  every  kind,  butcher's  meat,  poultry,  game,  and  broths  and 
soups  are  permissible.  Eggs  dressed  in  any  form,  cheese,  butter, 
cream — indeed,  every  form  of  fat  may  be  taken.  Bran  cakes, 
made  after  the  formula  of  Dr.  Camplin,  are  very  serviceable. 
They  are  entirely  free  from  starch,  consisting  of  bran,  eggs,  butter, 
and  milk.  Gluten  bread  and  biscuits,  prepared  by  Van  Abbott, 
Princes  Street,  London,  and  similar  bread  of  other  well-known 
firms,  is  to  be  recommended.  There  are  also  almond  rusks  and 
biscuits,  introduced  by  Dr.  Pavy,  and  made  by  Mr.  Blatchley, 
Oxford  Street.  These  may  be  taken  in  change  with  other  suit- 
able forms  of  diet. 

Dr.  A.  S.  Doukin  relates  the  case  of  a  girl  ten  years  of  age,  who 
was  successfully  treated  by  the  skim-milk  method.  The  urine 
ranged  from  1040  to  1045.  There  was  great  thirst,  excessive  ap- 
petite, polyuria,  and  great  loss  of  flesh.  A  restricted  meat  diet, 
iron,  and  Dover's  powder  at  night  failed  to  do  good,  but  when  the 
patient  was  placed  on  a  skim-milk  diet  the  specific  gravity  of  the 
urine  fell  to  1016  within  a  week,  and  on  the  thirteenth  day  of  the 
treatment  it  fell  to  1012,  and  not  a  trace  of  sugar  could  be  detected. 
In  little  more  than  six  weeks  she  had  gained  five  pounds  in  weight. 
"  This  case,  and  others  I  have  treated,  convince  me  that  diabetes 
is  curable  in  childhood  and  early  life,  when  the  disease  is  recog- 
nized earl}^  and  the  constitution  good.  On  the  other  hand  I  have 
found,  contrary  to  what  has  been  asserted  by  certain  writers,  that 
the  disease  is  quite  intractable,  especially  when  considerably  ad- 
vanced, in  subjects  at  or  beyond  the  middle  period  of  life."* 

Glycerin  should  take  the  place  of  sugar,  and  in  combination 
with  dilute  phosphoric  acid  it  allays  thirst.  Tea  and  coftee  with- 
out suo;ar  are  suitable. 

The  patient  should  drink  enough  water,  and  no  more  than  to 
allay  thirst,  and  lemon-juice  may  be  added  to  it. 

*  Clinical  Transactions,  vol.  ix,  p.  39. 


292  DISEASES   OF   CHILDREN. 

Exercise  in  the  open  air,  short  of  fatigue,  is  important. 

Drugs  have  little  or  no  influence  over  the  disease,  the  only  means 
that  hold  out  any  hope  of  cure  being  great  care  in  diet.  In  the 
experience  of  many  physicians,  opium,  however,  is  a  remedy  which, 
when  given  in  large  doses,  reduces  the  quantity  of  urine.  It  seems 
to  have  the  power  of  diminishing  the  appetite  and  thirst,  and  of 
inducing  sleep  and  allaying  irritability.  Some  physicians  have  a 
preference  for  codeia ;  it  is  equally  effective  and  less  constipating. 
Alkalies,  arsenic,  bromide  of  potassium,  lactic  acid,  and  peroxide 
of  hydrogen  are  all  useless.  A  powder  of  bicarbonate  of  soda 
and  rhubarb,  or  castor  oil,  by  correcting  the  secretions  and  reliev- 
ing constipation,  will  be  advisable  from  time  to  time.  Iron  may 
possibly  retard  the  progress  of  the  disease  for  a  period  where  the 
patient  is  ansemic,  and  there  are  no  better  forms  for  administration 
than  the  ferri  et  ammonite  citras,  the  tincture  of  the  perchloride, 
or  the  solution  of  dialyzed  iron.  Cod-liver  oil^  too,  is  useful  to 
support  the  strength. 

The  clothing  requires  to  be  warm,  and  flannel  should  be  worn 
next  the  skin.  A  residence  at  the  seaside,  or  even  sea-bathing  will 
be  advantageous  in  some  cases.  The  best  foreign  watering-places 
are  Carlsbad  and  Vichy. 

Finally,  all  those  hygienic  measures  ought  to  be  carried  out 
which  naturally  suggest  themselves  where  the  kidnej^s  are  doing 
excessive  work. 

Diabetes  insipidus  is  characterized  by  great  thirst  and  excessive 
discharge  of  pure  limpid  urine  of  low  specific  gravity  (1003  to 
1007),  containing  neither  sugar  nor  albumen.  In  a  table  of  seventy 
cases  given  by  Dr.  W.  Roberts,  seven  occurred  in  infancy,  and  fif- 
teen from  five  to  ten  years.  In  two  or  three  of  the  cases  the  dis- 
ease existed  at  birth.* 

As  in  diabetes  mellitus,  the  complaint  would  seem  sometimes  de- 
pendent on  gastric  and  intestinal  disturbance,  but  in  a  large  pro- 
portion of  cases  no  cause  can  be  ascertained.  Exposure  to  cold,  by 
checking  the  action  of  the  skin,  and  throwing  more  work  upon 
the  kidneys,  has  originated  the  complaint ;  drinking  large  draughts 
of  cold  water,  violent  muscular  exertion,  cerebral  tubercle,  febrile 
diseases,  blows  and  falls,  syphilis  and  hereditarj^  influences  appear 
to  be  among  the  most  frequent  causes.  The  exact  cause  has  been 
attributed  to  some  change  in  the  renal  capillaries,  which  allows  of 

*  On  Urinary  and  Kenal  Diseases,  1876,  p.  198. 


DISEASES   OF   THE   KIDNEYS   AND   URINARY   ORGANS.  293 

an  increased  quantity  of  watery  fluid  being  separated  from  the 
blood,  just  as  happens  in  a  hysterical  paroxysm.  Dr.  Handfield 
Jones  considers  that  the  Malpighian  capillaries  are  more  affected 
than  those  of  the  tubular  plexus.*  Some  authorities  consider  the 
disease  neurotic. 

Symptoms.— These  may  be  gradual,  the  disease  having  lasted 
from  infancy  to  maturity  in  some  cases,  or  it  may  come  on  quite 
suddenly.  "  In  two  cases  the  symptoms  commenced  immediately 
after  violent  muscular  efltbrt.  One  was  a  boy  of  twelve,  who 
strained  himself  in  pushing  a  cart-wheel  sunk  in  the  mud."t 
The  urine  is  colorless,  and  containing  a  very  small  proportion  of 
solid  constituents,  having  a  specific  gravity  nearly  as  low  as  water 
itself,  1003  to  1007  ;  it  is  of  acid  reaction,  but  quickly  becomes 
neutral  or  alkaline,  and  undergoes  decomposition.  The  skin  is 
generally  harsh  and  dry,  and  the  thirst  intense,  arising  no  doubt 
from  the  greater  quantity  of  urine  passed  than  in  saccharine  dia- 
betes The  general  health  is  often  wonderfully  preserved,  not- 
withstanding that  the  disease  may  have  existed  from  an  early 
period  of  life.  Dr.  W,  Roberts  mentions  the  fact  of  a  boy  of  ten 
years  of  age  under  his  care,  being  well  nourished  and  in  good 
health,  though  he  passed  fifteen  pints  of  urine  dailj''  for  several 
months.:}:  In  most  instances,  however,  symptoms  resembling  those 
met  with  in  diabetes  mellitus  are  present ;  there  is  loss  of  flesh, 
thirst,  voracious  appetite,  heat  and  drjaiess  of  the  skin,  pains  in 
the  limbs  and  loins,  and  irritability  of  temper.  The  disease  is  of 
uncertain  duration,  and  generally  terminates  in  phthisis  or  cere- 
bral disease. 

Pathology. — After  death  the  kidneys  have  been  found  degener- 
ated and  containing  very  small  abscesses.  The  base  of  the  brain 
has  revealed  miliary  tubercles  in  a  few  cases.  "The  pathology  of 
diabetes  insipidus  appears  to  be  somewhat  similar  to  that  of  diabetes 
mellitus,  only  that  the  renal  vessels  are  dilated  instead  of  the  hepatic 
ones."§ 

Treatment. — Valerian  in  large  doses  is  well  spoken  of  by  Trous- 
seau and  Handfield  Jones.  In  a  boy,  ten  years  of  age,  under  the 
care  of  Dr.  W.  Roberts,  the  valerianate  of  zinc  in  gradually  in- 

*  On  Functional  Nervous  Disorders,  1870,  p.  790. 

t  Eoberts,  op.  cit.,  p.  200.  J  Op.  cit.,  p.  204. 

?  Diabetes  Insipidus,  by  Lauder  Brunton,  M.D.,  Keynolds's  System  of  Medicine, 
vol.  V,  p.  430. 


294  DISEASES   OF  CHLLDEEST. 

creasing  doses,  up  to  twent}'  grains  daily,  reduced  the  urine  from 
fifteen  to  five  pints  a  day,  and  greatly  diminished  the  thirst.* 
Camphor,  iron,  ergot,  and  galvanism  have  been  tried  with  varj^- 
ing  success.  Mercury  and  iodide  of  potassium  have  been  found 
serviceable  where  the  disease  is  of  syphilitic  origin.  The  disease, 
however,  can  scarcely  be  considered  amenable  to  treatment.  Xo 
remedy  has  been  known  to  cure  it,  and  it  has  usually  a  fatal  ter- 
mination. A  normal  appetite,  and  the  absence  of  organic  compli- 
cation, may  be  looked  upon  as  favorable  signs. 


CHAPTER   XXY. 

DISEASES    OF    THE    PERITONEUM. 

ActjTE  Peritonitis:  Symptoms — Causes — Morhid  appearances — Diagnosis  and  prog- 
nosis— Treatment.  Chronic  Peritonitis:  Causes  and  treatment.  Tuberculae 
Peritonitis  (Tabes  mesenterica)  :  Symptoms — Causes— Consequences — Morbid 
appearances — Diagnosis  and  treatment    Enlargement  of  the  Abdomen. 

Acute  peritois'Itis  is  a  very  rare  disease  in  children,  the  mucous 
membranes  being  much  more  prone  to  inflammation  than  the 
serous  in  the  young.  AYhen  it  is  present  the  symptoms  resemble 
thdse  observed  in  the  adult.  In  the  new-born  infant,  peritonitis 
is  more  common  than  in  later  childhood,  and  syphilis  appears  to  be 
a  frequent  cause  of  it  at  that  early  period.  There  ma,}^  be  con- 
stitutional evidence  in  the  hoarse  voice  and  copper-colored  erup- 
tion over  the  body.  Eilliet  and  Barthez  met  with  a  dozen  cases 
of  acute  peritonitis.  "  M.  Thore  found  that  acute  peritonitis  ex- 
isted in  about  six  per  cent,  of  all  the  infants  who  died  at  the 
Hospice  des  Enfans  trouves."t 

Peritonitis,  which  is  rarely  a  primary  disease,  may  commence 
rather  suddenly  with  rigors  and  shivering ;  more  frequently  it 
comes  on  gradually  in  the  course  of  some  other  disease,  with  pain 
in  some  part  of  the  abdomen,  as  about  the  umbilicus  or  hypogas- 
trium,  and  from  thence  it  spreads  over  the  whole  abdominal  region. 
The  slightest  pressure  is  intolerable,  not  even  the  weight  of  the 
bedclothes  can  be  borne  ;  the  child  lies  on  his  back  with  his  knees 

*  Op.  cit.,  p.  215. 

t  Diseases  of  Children,  Dr.  Churchill,  1858,  p.  592. 


DISEASES   OP   THE   PERITONEUM.  295 

drawn  np,  to  relax  the  muscles  of  the  abdomen.  The  face  wears 
an  anxious  and  painful  expression,  the  lips  are  compressed,  and 
the  nostrils  active ;  the  breathing  is  short  and  thoracic,  for  as  the 
diaphragm  descends  on  full  inspiration,  the  abdominal  pain  is  in- 
creased, but  the  epigastrium  may  rapidly  rise  and  fall  at  the  same 
time.  In  such  cases  I  have  known  the  respirations  to  reach  80 
per  minute.  The  bowels  may  be  constipated  or  relaxed,  and  the 
urme  scanty  and  high-colored.  Occasionally  the  bladder  is  para- 
lyzed, and  the  urine  has  to  be  drawn  off.  The  tongue  is  clean, 
or  it  has  a  whitish  fur  upon  it,  which  soon  becomes  dry.  There  is 
thirst  and  loss  of  appetite.  The  disease  may  drag  on  for  some 
days,  during  which  the  skin  becomes  moist  and  damp,  the  pulse 
feeble  and  fluttering,  and  there  is  vomiting  of  cofiiee-colored  fluid, 
besides  gaseous  distension  of  the  abdomen,  torpor  of  the  mental 
faculties,  and  death  by  asthenia  is  often  the  result.  Sometimes 
the  disease  is  more  limited  and  circumscribed ;  it  does  not  extend 
over  the  whole  abdomen,  and  yields  to  the  remedies  employed. 

Causes. — Peritonitis  may  arise  from  cold,  wet,  fatigue,  and  bad 
living.  A,  fatal  ease  is  recorded  by  Mr.  Jeaftreson,  of  JSTevvcastle- 
oii-Tj-ne,  of  a  girl  fifteen  years  of  age,  from  perforation  of  the 
rectum  with  a  walking-stick,  which  her  uncle  was  holding  between 
his  legs  whilst  she  was  jumping  on  his  knee.  A  rent  was  dis- 
covered in  the  anterior  wall  of  the  rectum,  through  which  the 
finger  could  be  passed  into  the  peritoneal  cavity.  Peritonitis 
ensued,  and  death  took  place  within  forty-eight  hours*  It  some- 
times occurs  as  a  sequel  to  scarlatina. 

Dr.  Burney  Yeo  has  related  an  instructive  case  of  "  infective 
peritonitis  "  in  a  boy  twelve  years  of  age,  complicating  an  attack 
of  whooping-cough,  and  terminating  fatally.  There  was  pneu- 
monic infiltration  of  the  left  lung  and  fluid  in  the  left  pleural  sac. 
He  quotes  from  Ziemssen's  Cyclopcedia  to  the  eftect,  that  pus  may 
pass  from  the  pleural  cavity  through  the  diaphragm  into  the  peri- 
toneum, and  there  set  up  fatal  peritonitis.f  Several  cases  have 
come  under  my  notice  in  which  septicaemia  in  women,  springing 
from  operations  involving  the  peritoneum,  has  extended  to  the 
pericardium  and  pleural  cavities. 

Peritonitis  has  followed  inflamxmation  of  the  csecum,  from  the 
impaction  of  a  foreign  body  in  the  vermiform  appendix.     The 

*  Brit,  Med.  Journ.,  1874,  vol,  ii,  p.  403. 
t  Ibid.,  December  7tb,  1878,  p.  827, 


29G  .  DISEASES    OF    CHILDPwEX. 

disease  may  terminate  iu  twenty-four  hours,  or  last  four  or  five 
weeks.  It  may  also  follow  injuries  or  operations  on  the  abdomen, 
as  tapping. 

The  morbid  changes  detected  after  death,  are  the  effusion  of 
lymph  over  the  peritoneal  surface  and  amongst  the  intestines  ;  the 
vessels  of  the  peritoneum  and  abdominal  wall  are  injected  ;  and 
there  is  clear  or  lemon-tinted  serum  in  the  peritoneal  cavity,  or 
even  a  thick  or  thin  muco-purulent  matter.  The  spleen  and  liver 
may  be  coated  with  lymph.  -  In  a  case  related  by  Dr.  West,  of  a 
boy,  nine  3-ears  of  age,  a  pint  of  pus  was  found  in  the  right  pleura, 
the  inflammation  having  extended  from  the  abdomen  to  the 
thorax.*     This  is  not  an  uncommon  coincidence. 

The  diagnosis  from  colic  has  been  already  given, f  but  we  may 
repeat  that  in  peritonitis  the  constitutional  symptoms  are  more 
severe,  the  pain  is  increased  on  pressure,  it  is  not  paroxysmal,  and 
the  pulse  soon  becomes  quick  and  feeble.  As  the  disease  assumes 
a  more  chronic  form,  crepitation  can  often  be  felt  by  the  hand, 
when  it  is  laid  on  the  abdomen  above  the  effused  lymph. 

The  prognosis  is  grave,  unless  the  inflammation  is  limited  in  ex- 
tent and  moderate  in  decree. 

Treatment. — Where  the  patient  is  strong  enough,  a  few  leeches 
should  be  applied  to  the  abdomen,  and  it  may  be  even  necessary 
to  repeat  them.  This  requires  to  be  carried  out  effectually  if  the 
case  be  seen  early,  and  the  child  is  able  to  bear  depletion  well.  It 
offers  the  best  chance  of  relief.  Then  warm  light  poultices  are 
very  comforting,  and  they  should  be  frequently  renewed.  Small 
doses  of  calomel,  combined  with  opium  or  Dover's  powder,  are  also 
serviceable  to  allay  pain  and  abate  inflammation.  Opium  is  in- 
valuable in  peritonitis,  and  should  be  given  freely.  If  the  bowels 
are  constipated  for  any  length  of  time,  warm-water  enemata,  and 
an  elastic  tube  passed  up  the  anus  to  favor  the  escape  of  gas  will 
be  advisable.  The  diet  should  consist  of  milk-and-water,  thin  ar- 
rowroot, or  weak  beef  tea,  according  to  the  state  of  the  stomach 
and  the  strength  of  tbe  patient. 

When  peritonitis  succeeds  scarlet  fever  the  symptoms  are  less 
acute,  but,  owing  to  the  defective  elimination  of  urine  by  the  kid- 
neys, dropsy  is  very  apt  to  arise. 

Chronic  feriionilis  may  be  the  sequel  of  an  acute  attack,  or  it 

*  Diseases  of  Infancy  and  Cli'ldhood,  4tli  edit.,  p.  618. 
f  See  Chap.  XVII,  On  Constipation  and  Colic. 


DISEASES   OF   THE   PERITONEUM.  •  297 

may  arise  from  the  irritation  of  tubercles  in  the  peritoneum  of 
strumous  subjects.  The  symptoms  are  abdominal  pain  and  tender- 
ness, with  more  or  less  swelling ;  sometimes  crepitation  can  be  felt 
from  the  efiusion  of  Ij-mph  between  the  folds  of  the  intestines.  If 
this  does  not  cause  fatal  obstruction  the  case  may  recover,  but 
w^jere  the  complaint  is  due  to  the  irritation  of  tubercle,  the  mesen- 
teric glands  are  apt  to  become  involved,  febrile  disturbance  comes 
on  in  the  evening,  food  is  vomited,  and  death  takes  place  from 
phthisis  or  exhaustion. 

The  treatment  consists  in  supporting  the  general  strength  by  nu- 
tritious and  easily  digestible  food,  such  as  milk,  raw  eggs,  cod-liver 
oil,  or  malt  extract.  A  blister  to  the  abdomen  is  sometimes  of 
service. 

Tabes  mesenterica  is  a  chronic  tubercular  disease  of  the  mesenteric 
glands,  and  is  sometimes  associated  with  tubercular  peritonitis. 
Enlargement  of  the  abdomen  is  the  first  symptom  which  attracts 
notice,  and  there  may  be  some  amount  of  fluid  in  the  peritoneal 
cavity.  A  child  may  be  quite  well  and  strong  till  he  is  seized  with 
whooping-cough,  or  one  of  the  exanthemata,  and  from  that  period 
the  disease  commences.  He  gradually  loses  flesh  and  strength, 
and  if  he  has  been  accustomed  to  run  about  he  now  ceases  to  do  so  ; 
he  complains  of  being  tired,  and  wishes  to  be  nursed  by  his  mother. 
The  complaint  sometimes  commences  with  looseness  of  the  bowels, 
the  motions  being  thin  and  yeastlike,  containing  mucus  or  even 
streaks  of  blood.  Then  the  abdomen  begins  to  swell,  and  is  tender 
on  pressure,  colicky  pains  are  common,  and  the  child  will  lie  on 
his  back  in  bed  with  his  legs  drawn  up.  He  often  cries  out  with 
pain,  and  the  face  is  pinched  and  drawn.  On  examination,  the 
liver  may  sometimes  be  felt  below  the  ribs,  and  the  spleen  also. 
As  the  case  goes  on,  the  abdomen  becomes  irregular  in  shape,  and 
in  some  cases  crepitus  can  be  detected  when  the  hand  is  passed 
lightly  over  it,  from  the  efi"usion  of  semi-organized  lymph.  As 
the  disease  advances,  an  irregular  nodular  mass  may  be  felt  about 
the  umbilicus,  or  to  one  side  of  it.  This  is  frequentl}^  found  to 
consist  of  omentum,  mesentery,  and  intestines  glued  together,  and 
among  this  mass  there  are  enlarged  mesenteric  glands,  sometimes 
the  size  of  a  filbert.  As  the  disease  goes  on,  some  degree  of  ascites 
is  present,  and  the  lumbar  regions  are  dull  on  percussion.  Emacia- 
tion sets  in,  there  is  constant  vomiting  and  diarrhoea,  the  pulse  be- 
comes quick  and  small,  the  temperature  rises  in  the  evening,  and 


298  DISEASES    OF   CHILDREN. 

the  child  dies  exhausted  or  in  convulsions.  The  disease  ma}'-  ter- 
minate by  bronchia]  phthisis,  puhxionarj  consumption,  or  tubercu- 
lar meningitis. 

Disease  of  the  mesenteric  glands  may  lead  to  intestinal  occlusion. 
In  the  case  of  a  boy,  four  years  of  age,  who  came  under  my  care  at 
the  Samaritan  Hospital  in  1878,*  there  was  considerable  distension 
of  the  abdomen,  and  symptoms  of  obstruction  a  few  days  before 
death,  which  was  preceded  by  coffee-grounds  vomiting,  convulsions, 
and  unconsciousness.  After-  death,  the  intestines  and  omentum 
w^ere  found  glued  together  in  a  large  mass,  and  adherent  to  the 
peritoneum  at  the  umbilicus  and  brim  of  the  pelvis. 

The  diagnosis  is  generally  not  difficult;  the  liver  is  often  healthy, 
and  as  the  disease  advances  the  belly  becomes  irregular  over  its 
surface,  and  more  painful  than  in  ascites.  There  is  often  a  fluctu- 
ation in  the  temperature,  and  the  signs  of  tubercular  mischief  in 
other  organs  as  the  complaint  advances. 

The  treatment  consists  in  maintaining  the  general  strength  and 
meeting  the  chief  symptoms  as  they  arise,  but  it  is  very  unsatis- 
factory. If  there  is  any  amount  of  peritonitis,  opium  in  some 
shape  or  other  must  be  given,  and  linseed  poultices  be  applied  to 
the  abdomen  to  relieve  the  pain  and  tenderness.  When  diarrhoea 
is  very  active,  a  little  chalk  mixture  with  catechu  or  krameria 
(Form.  31,  32)  will  be  necessary,  and  the  diet  must  consist  of  rice, 
milk,  and  arrowroot.  The  treatment  is  much  the  same  as  should 
be  employed  in  chronic  diarrhoea.  When  the  bowels  are  quiet  the 
syrup  of  the  iodide  of  iron  and  cod-liver  oil,  if  the  stomach  will 
retain  it,  should  be  prescribed.  I  have  found  painting  the  abdo- 
men night  and  morning  with  a  weak  tincture  of  iodine  (1  in  7) 
useful,  and  then  applying  a  flannel  bandage.  I  prefer  this  to  rub- 
bing any  kind  of  ointment  into  the  abdomen.  When  the  child  is 
well  enough  to  be  moved,  change  of  air  to  the  seaside  will  be  ad- 
visable. 

Enlargement  of  tlie  abdomen\s  very  commonly  observed  in  delicate 
children  who  are  rickety  or  of  a  strumous  habit  of  bodj',  but  I 
have  seen  it  in  fairly  developed  children  who. are  otherwise  healthy. 
The  parents  observe  that  the  abdomen  is  disproportionately  large 
to  the  rest  of  the  body,  and  that  it  becomes  very  much  so  after 
food.  In  many  cases  the  increased  size  is  chiefly  due  to  flatus  in 
the  intestines,  to  constipation,  and  improper  feeding.    The  abdomi- 

*  Lancet,  Aug.  10th,  1878,  p.  185. 


ASCITES.  299 

nal  walls  yield  and  become  overstretched  ;  the  abdomen  is  soft, 
pressure  gives  no  pain,  and  no  tumor  can  be  felt.  This  condition 
is  sometimes  seen  with  congestion  of  the  liver,  and  with  that  con- 
dition known  as  ''  pot  bell}'."  I  have  noticed  it  not  rarely  in  deli- 
cate children  after  an  acute  illness,  as  whooping-cough  or  measles. 
In  children  brought  up  by  hand,  with  delayed  dentition,  it  is  not 
uncommon.  It  arises  chiefly  from  the  accumulation  of  gas  in  the 
intestines;  a  clear  tympanitic  note  is  heard  all  over  the  abdomen, 
especially  in  the  left  hypochondriura,  and  in  both  flanks.  The 
epigastrium  is  prominent,  either  from  undue  distension  of  the 
stomach,  or  of  the  transverse  colon  behind  it.  "  The  little  child's 
abdomen  is  large  because  its  abdominal  ar^d  intestinal  muscles  are 
weak,  its  pelvis  is  shallow  and  small,  its  diaphragm  flat,  and  its 
liver  and  spleen  large,  and  because  much  flatus  is  formed  in  its 
small  intestines,  especially  during  the  digestive  process."* 

Enlargement  of  the  abdomen,  when  seen  in  connection  with 
tubercular  peritonitis,  causes  pain  on  pressure ;  the  abdomen  is 
irregular  in  outline,  partly  from  the  enlarged  viscera  beneath  or 
from  semi-organized  lymph  ;  the  bowels  are  often  very  loose,  and 
the  belly  painful ;  the  face  is  pinched,  and  the  child  rapidly  loses 
flesh. 

The  liver  may  remain  very  large  without  any  impairment  of  the 
general  health,  a  condition  we  sometimes  see  in  connection  with 
the  strumous  diathesis  and  freneral  cachexia. 


CHAPTER    XXVI. 

ASCITES. 


Causes — Nature — Sijmjjtoms — Diagnosis — Treatment — Iron — Saline  aperients — 
Copaiba — Paracentesis. 

Disease  of  the  liver,  by  obstructing  the  portal  circulation,  is 
the  most  common  cause  of  ascites  in  children,  but  it  may  arise 
also  from  great  enlargement  of  the  spleen,  from  chronic  peritonitis, 
and  from  tabes  mesenterica.  The  enlarged  glands  in  the  latter 
disease  cause  friction  and  irritation  of  the  peritoneum,  and  so  lead 

""  On  Extra-pelvic  Tumors  of  tlie  Abdomen,  by  Sir  W.  Jenner,  Bart.,  M.D.,  Brit. 
Med.  Journ.,  Jan.  2d,  1869,  p.  2. 


300  DISEASES   OF   CHILDREN. 

to  serous  effusion  into  the  cavity.  It  has  been  supposed  to  arise 
from  the  pressure  of  enlarged  lymphatic  glands  on  the  portal  vein 
near  the  liver.*  It  appears  to  me  that  cachexia  and  anaemia  are 
not  uncommon  causes  of  this  form  of  dropsy.  In  the  absence  of 
any  history  of  acute  illness,  and  if  organic  disease  is  not  present, 
it  seems  a  reasonable  inference  that  a  loss  of  tone  in  the  perito- 
neum or  lymphatics  may  favor  the  secretion  of  serum  into  the 
peritoneal  cavity.  I  have  published  a  case  in  illustration  of  this 
view.f 

Symptoms. — The  abdomen  is  more  or  less  prominent  in  propor- 
tion to  the  amount  of  fluid  present.  If  the  distension  is  great  the 
diaphragm  is  pushed  upwards,  and  there  may  be  some  dulness  on 
percussion  and  defective  expansion  in  the  lower  lobes  of  the  lungs. 
Over  the  seat  of  effusion  the  percussion-note  is  dull,  chiefly  heard 
in  the  flanks,  and  more  in  one  flank  than  in  the  other  wlien  the 
patient  turns  on  his  side.  Along  the  anterior  surface  of  the  abdo- 
men the  percussion-note  is  clear,  and  this  varies  according  to  the 
amount  of  air  which  the  intestines  contain ;  the  higher  they  float 
the  more  tympanitic  is  the  note.  The  constitutional  symptoms 
are  a  gradual  decline  in  the  general  health;  the  skin  is  dry;  the 
bowels  are  usually  constipated ;  the  urine  is  scanty,  acid,  and  high- 
colored,  from  the  presence  of  urates,  which  may  be  whitish  instead 
of  pink ;  there  is  often  thirst  and  a  voracious  appetite.  As  the 
abdominal  distension  increases,  the  superficial  veins  become  en- 
larged and  tortuous ;  the  child  is  thin  and  wasted,  the  features 
are  pinched,  and  the  nights  restless  and  wakeful.  As  the  disease 
advances  the  emaciation  increases,  a  hectic  flush  appears  on  the 
cheeks  at  night,  the  pulse  becomes  rapid  and  feeble,  respiration  is 
accelerated,  and  death  takes  place  from  exhaustion. 

The  diagnosis  mainly  rests  on  the  primary  and  uniform  swelling 
in  the  abdomen,  without  any  oedema  of  the  legs,  and  the  absence 
of  swelling  in  the  upper  parts  of  the  body,  the  presence  of  disease 
in  the  liver,  and  the  high-colored,  scanty,  and  non-albuminous 
urine.  As  ovarian  cysts  have  been  met  with  in  children,  this  fact 
should  be  borne  in  mind  in  all  cases  of  doubtful  diagnosis.  Hydatid 
cysts  of  the  liver,  hydronephrosis,  enlarged  spleen,  and  mesenteric 
glands  must  also  be  taken  into  consideration,  and  the  conditions 

*  Brit.  Med.  Journ.,  Nov.  20th,  1875. 

t  Ascites  in  a  Young  Child ;  Treatment  by  Paracentesis  and  Copaiba ;  Eecovery, 
by  W.  n.  Day,  M.D.,  Clin.  Trans.,  1877,  p.  164. 


ASCITES.  301 

belonging  to  each  carefully  investigated.  The  chief  points  of 
diagnosis  in  the  case  of  ovarian  tumors,  as  distinguished  from 
ascites,  are  to  be  found  in  Mr.  Spencer  Wells's  work.* 

Treatment. — This  to  a  great  extent  depends  upon  the  cause.  If 
there  is  disease  of  the  heart,  lungs,  or  kidneys,  these  affections 
must  receive  appropriate  treatment;  but  usually,  however,  the 
mischief  is  seated  in  the  liver,  which  we  must  endeavor  to  over- 
come. Whatever  may  be  the  cause  which  has  induced  the  disease, 
the  bowels  should  be  kept  freely  open,  and  for  this  purpose  the 
compound  jalap  powder,  given  early  every  morning,  is  a  good 
remedy  to  drain  off  the  fluid.  When  the  urine  is  scanty  and  high- 
colored,  digitalis  and  citrate  of  potash  will  relieve  the  congestion 
of  the  kidneys  and  act  as  a  brisk  diuretic.  '  Then  the  syrup  of  the 
iodide  of  iron  is  a  good  tonic,  or  the  tincture  of  the  perchloride 
of  iron  may  be  given.  Ascites  has  over  and  over  again  yielded  to 
tonics,  and  they  ought  to  have  a  steady  and  ftiir  trial  where  the 
effusion  appears  to  be  independent  of  any  organic  lesion. f 

If  these  remedies  fail,  as  they  frequently  will  do,  copaiba  is  an 
excellent  remedy,  according  to  some  authorities,  acting  as  a  diu- 
retic and  carrying  off  much  fluid  by  the  bowels.  In  the  case  just 
alluded  to,  I  believe  its  action  was  that  of  a  general  tonic  and  not 
that  of  a  diuretic.  It  does  not  disagree  with  digestion  or  appe- 
tite. Other  cases  of  ascites  are  recorded  which  have  yielded  to 
the  use  of  copaiba.  Dr.  Liveing's  two  cases  of  improvement 
seemed  due  to  its  action  as  a  diuretic,  but  it  should  be  held  in 
mind  that  the  urine  was  albuminous  in  both,  and  remained  so 
when  the  patients  left  the  hospital,  although  the  dropsy  had  en- 
tirely disappeared.  There  was  chronic  (Bright 's)  disease  in  one, 
and  a  soft  systolic  bruit  at  the  cardiac  apex  in  the  other,  so  that 
the  relief  at  best  was  only  temporary.:}: 

When  all  drugs  have  proved  unavailing,  and  the  increasing 
pressure  causes  pain  and  discomfort,  paracentesis  must  be  had 
recourse  to,  and  the  operation  should  be  performed  before  the 
abdomen  is  too  much  distended.  The  tonic  treatment  and  the 
copaiba  may  be  again  employed  after  the  tapping,  and  a  perma- 
nent cure  may  follow  the  operation  in  some  cases  when  it  has 

*  Diseases  of  the  Ovaries,  1872,  p.  125. 

f  Case  of  Ascites  treated  successfully  with  Tonics,  by  J.  S.  Bristowe,  M.D.,  Clin. 
Trans.,  1869,  p.  12. 

X  Cases  of  Ascites  treated  with  Copaiba,  Clin.  Trans.,  1870,  p.  30. 


302  DISEASES    OF    CHILDREN. 

been  twice  performed.     Sucli  cases  seem  generally  due  to  liver 
disorder,  or  to  debility  and  ansemia. 


CHAPTER    XXVIT. 


INTESTINAL    WORMS. 


Varieties  of — OxYURis  VERMrcuLARi^,  or  Ascaris  Ver^iiculaeis — Ascarides 
(Threadworm) — Ascaris  lumbricoides  (Round-worm)  :  Symptoms — Causes — 
Treatment.  Trichocephalus  dispar  (Long  Threadworm) — T^nia  or  Tape- 
worm :  Treatment. 

The  presence  of  worms  in  the  intestinal  canal  is  one  of  the  com- 
monest troubles  of  childhood.  Worms  produce  in  some  cases  an 
amount  of  constitutional  disturbance  and  local  irritation  which 
the  best  observers  may  be  pardoned  if  they  attribute  to  specific 
disease. 

It  is  with  the  two  nematodes,  Oxyuris  and  Ascaris^  that  we  have 
generally  to  deal  in  childhood.  The  Oxyuris  vermiculcuis,  or 
threadworm,  has  its  headquarters  in  the  csecum,  but  frequently 
descends  to  the  lower  part  of  the  large  intestine  or  rectum.  AVorms 
infest  children,  whether  living  in  country  districts  or  in  the  con- 
fined dwellings  of  houses  and  cities  ;  but  their  presence  is  not  neces- 
sarily incompatible  with  previously  good  health.  They  are  not 
uncommon  in  strumous  subjects,  or  in  children  laboring  under 
chronic  disease,  in  whom  the  digestive  and  assimilative  functions 
are  at  fault — where  there  is  subacute  inflammation  of  the  intes- 
tinal glands  (muco-enteritisj.  They  are  often  spoken  of  as  "  ascar- 
ides,"  since  Linnseus  placed  their  species  under  the  genus  Ascaris. 
But  the  term  is  confusing,  as  they  have  long  been  classified  under 
a  separate  genus,  Oxyuris,  and  must  not  be  confounded  with  the 
long  worm  Ascaris  lumbricoides. 

In  a  mass  of  Oxyuri,  or  threadworms,  the  majority  are  females, 
and  aj)pear  like  little  moving  pieces  of  thread,  about  a  quarter  of 
an  inch  long,  with  a  pointed  tail.  The  males  are  shorter,  and  keep 
the  anal  end  of  their  body  more  or  less  coiled  up.  The  eggs  are 
commonly  introduced  by  the  habit  which  children  have  of  biting 
their  nails.     They  are  hatched  in  the  stomach,  the  larvae  under- 


INTESTINAL   WORMS.  303 

going  their  subsequent  growth  and  metamorphosis  within  the 
alimentary  canaL 

Symptoms. — The  appearance  of  the  parasite  in  the  motions  is  of 
course  the  only  pathognomonic  sign  ;  as  it  almost  exclusively 
inhabits  the  large  intestine,  it  is  very  rarely  vomited  like  the  true 
Ascaris,^  though  the  constitutional  symptoms  are  the  same  in  both 
affections.  But  the  presence  of  threadworms  in  the  bowels  excites 
symptoms  of  reflex  irritation,  by  which  they  may  be  suspected 
before  they  are  seen.  Itching  of  the  nose  and  anus  is  the  most 
frequent  feature  of  this  kind.  At  night  the  irritation  becomes  so 
great  that  sleep  may  be  prevented,  and  in  any  case  the  child  is 
certain  to  indulge  in  the  dirty  habit  of  continually  touching  the 
anus.  The  finger  nails  often  excoriate  the  skin  around  that  orifice, 
leaving  marks  once  erroneously  believed  to  be  caused  by  the  biting 
of  the  worms.  The  irritation  causes  a  free  discharge  of  nmcus 
from  the  lining  membrane  of  the  intestine,  and  the  child  con- 
stantly voids  this  at  stool  by  straining,  and  thereby  often  produc- 
ing prolapsus  ani.  The  worms  appear  in  the  motions  in  great 
numbers,  and  escape  of  their  own  accord  from  the  anus  ;  they  even 
enter  the  vagina  in  female  children,  and  set  up  leucorrhoea.  Symp- 
toms of  vesical  irritation  also  develop  themselves,  sometimes  simu- 
lating calculus,  more  usuall}^  seen  in  the  form  of  a  frequent  desire 
to  pass  water.  Priapism  is  also  not  unfrequently  observed  in  male 
children  troubled  with  threadworms,  and  Lallemand  was  of  opinion 
that  in  this  manner  the  parasites  produced  the  habit  of  masturba- 
tion, with  its  consequent  evils.  All  general  disorders,  especially 
those  of  the  nervous  system,  are  aggravated  by  the  presence  of 
threadworms  ;  this  particularly  applies  to  the  spastic  contractions 
of  muscles  which  produce  some  forms  of  talipes. 

Treatment. — As  the  threadworms  are  mostly  confined  to  the 
lower  part  of  the  large  intestine  they  are  within  the  access  of 
enemata.  An  injection  of  infusion  of  quassia,  mixed  with  table- 
salt  or  sulphate  of  iron,  is  perhaps  the  most  effectual  method  of 
treatment ;  but  as  it  seldom  or  ever  effects  a  cure  at  once  it  must 


*  Dr.  Goubert,  in  his  recent  work,  Des  Vers  chez  les  Enfants,  remarks  thai  "  they 
can  never  reach  the  stomach  or  tlie  small  intestine,  and  consequently  can  never  be 
thrown  up  in  vomiting,  as  Brera  and  P.  Franck  have  asserted."  But  Dr.  Parapa  de- 
scribes a  case  wliere  a  child  aged  ten  was  ti'oubled  by  Oxyuri  appearing  in  her  mouth 
_in  the  evening,  Lond.  Med.  Eecord,  1878,  p.  Q'lL 


304  DISEASES   OF   CHILDEEN. 

be  frequently  repeated.*  Lime-water  is  another  good  application.f 
Since  the  bowels  generally  act  irregularly  when  threadworms  have 
remained  long  in  the  large  intestine,  the  treatment  should  be  com- 
menced in  all  cases  by  the  administration  of  an  alterative  aperient, 
such  as  gray  powder  and  rhubarb,  or  rhubarb  and  soda.  When 
children  are  strong  enough,  one  grain  of  calomel  and  three  of 
scammonj*  is  a  good  aperient  to  start  with.  The  mucous  discharge 
produced  bj'  the  irritation  of  the  parasites  appears  to  afford  lodg- 
ment for  them,  and  so  must  itself  be  cleared  away  to  insure  their 
complete  expulsion.  They  rapidlj'  reappear.  Two  or  three  grains 
of  santonin  at  night,  followed  by  a  dose  of  castor  oil  in  the  morn- 
ing, will  efi'ect  the  discharge  of  these  threadworms.  Afterwards 
steel  wine,  or  the  tincture  of  perchloride  of  iron,  will  be  useful. 
"  Iron,  in  these  circumstances,  acts,  I  believe,  not  merely  as  a  tonic, 
but  also  by  its  admixture  with  the  secretions,  it  renders  the  intes- 
tinal mucous  membrane  unsuitable  to  serve  as  a  nidus  for  the  re- 
production of  the  worms.":]: 

Dr.  E.  Liveing  informs  me  that  as  a  local  application,  about  an 
equal  quantity  of  mercurial  ointment  and  lard,  smeared  on  the  anal 
aperture  at  night,  will  prove  effectual  in  relieving  the  itching  and 
preventing  the  escape  of  the  worms  and  ova.  The  child  thus  gives 
up  the  habit  of  scratching  with  the  fingers,  by  which  the  ova  are 
introduced  under  the  nails  and  then  convej^ed  to  the  mouth. 

Children  should  not  be  permitted  to  drink 'unfiltered  water,  nor 
to  eat  salad,  radishes,  or  cress,  unless  thoroughly  washed,  as  the 
ova  of  the  Oxyuris  are  possibly  transmitted  in  this  way.  It  is 
significant  that  of  country  children,  the  peasant  class  are  the  most 
subject  to  intestinal  worms.  Of  course  they  have  more  opportu- 
nities of  drinking  out  of  wells  or  brooks,  and  of  eating  raw  food, 
than  have  young  people  in  town.  So  long  as  infants  are  fed  with 
breast-milk  they  are  not  troubled  with  worms. 

*  Formula  46 : 

R.  Sodii  chlorid.  vel 

Ferri  eiilph.,        .........     ^,j 

Inf.  quassiae,         .........     Oj 

Fiat  enema.     A  third  part  to  be  used  every  morning, 
f  Formula  47 : 

R.  Liquor,  calcis,     .         .         .         .         .         .         .         .         •     ^^j 

Fiat  enema.     To  be  used  every  morning. 
X  West,  on  Diseases  of  Infancy  and  Childhood,  1859,  p.  637. 


INTESTINAL   WORMS.  305 

The  Ascaris  lumbi'icoides,  or  round-worm,  by  no  means  rare,  is 
however  less  frequent  than  the  threadworm.  It  is  best  to  dis- 
tinguish the  two  species  by  their  English  names,  for,  as  I  have 
above  remarked,  the  generic  name  Ascaris  is  still  retained  by 
many  in  speaking  of  the  Oxyuris^  though  the  two  worms  are  very 
different  in  appearance.  The  round-worm  is  a  very  large  parasite, 
always  several  inches  in  length  when  full  grown,  and  sometimes  a 
foot  long.  It  bears  a  strong  superficial  resemblance  to  the  com- 
mon earth-worm  [Lumbricus  terrestris)^  which  is  not  a  nematode 
at  all,  nor  even  does  it  belong  to  the  class  Scolecida.  The  earth- 
worm is  included  in  the  sub-kingdom  Annulosa,  and,  like  the 
leech,  it  differs  from  the  Crustacea  in  lacking  true  feet.  Inde- 
pendently of  the  different  internal  structure  this  worm  is  much 
stouter  than  the  Ascaris,  and  bears  eight  rows  of  minute  bristles, 
which  give  its  integuments  a  rough  feeling. 

The  male  Ascaris  is  rarer  and  smaller  than  the  female,  and  its 
anal  extremity  is  curved  as  in  Oxyaris.  Davaine  has  shown  that 
the  female  produces  over  50,000  eggs !  That  observer,  confirming 
previous  researches,  has  proved  that  the  eggs  do  not  hatch  in  the 
intestine  of  the  child  in  whom  the  parent  worm  dwells.  The  ova 
are  expelled  in  the  fseces,  and  find  their  way  into  sewage-water, 
etc.  They  are  absolutely  indestructible  by  any  natural  force, 
though  boiling,  or  many  other  artificial  processes,  will  destroy 
them.  They  are  introduced  into  the  bowels  by  unfiltered  drink- 
ing-water, etc.,  and,  being  dissolved  by  the  action  of  the  digestive 
juices,  the  embryos  which  they  contain  are  set  free.* 

Not  only  does  the  Ascaris  difter  from  the  Oxyuris  generically,, 
but  it  difiers  also  in  habitation.  It  dwells  in  the  small  intestine,, 
often  in  numbers,  but  never  in  such  masses  as  are  seen  in  bad 
cases  of  accumulations  of  threadworms  in  the  rectum  It  is  not 
unfrequently  vomited.  A  countrywoman  in  one  of  the  wards  of 
the  Samaritan  Hospital,  in  the  autumn  of  1878,  brought  up  a  lum- 
bricus during  an  attack  of  sickness  after  ovariotomy.  Mr.  Albam 
Doran  informs  me  that  a  man  in  St.  Bartholomew's  Hospital,  in 

*  Davaine,  Traitd  des  Entozoaires  et  des  Maladies  Vermineuses  de  THomme  et  des 
Animaux  Domestiques.  Goubert's  work,  already  quoted,  contains  a  very  clear,  yet 
short,  description  of  Ascaris  and  Oxyuris.  The  works  of  Cobbold  and  Kiichenmeister- 
should  be  consulted  by  tliose  desiring  minute  details  with  regard  to  entozoa. 

20 


306  DISEASES   OF   CHILDREN. 

1870,  vomited  several  when  dying  of  dysentery  contracted  a  few 
months  before  in  Buenos  Ayres.  Still  oftener  do  children  throw 
up  round-worms,  and  in  violent  retching  the  parasites  may  be 
expelled  through  the  nares  as  well  as  by  the  mouth;  or  they  may 
remain  in  the  nasal  cavities  a  short  time,  and  suddenly  appearing 
out  of  the  nostrils  cause  great  alarm  to  the  patient  and  his  parents. 
The  Ascaris  sometimes  escapes  out  of  the  cavities  of  abscesses 
formed  after  perityphlitis  when  such  collections  of  pus  are  opened 
spontaneous!}'  or  surgically.  They  may  also  enter  the  peritoneal 
cavity  through  tjqjhoid  or  gastric  perforating  ulcers.  But  Davaiue 
has  shown  that  it  is  quite  impossible  for  the  worm  to  force  its 
own  way  through  the  coats  of  the  intestine,  as  it  is  not  provided 
with  cutting  or  boring  appendages. 

Symptoms. — This  worm  gives  more  trouble  than  the  Oxyuns^ 
and  often  produces  much  reflex  irritation.  The  bowels  act  in  an 
irregular  manner,  dull  pain  is  felt  around  the  umbilicus  or  in  the 
epigastrium,  and  there  is  itching  at  the  nose  and  anus.  Any 
malady  from  which  the  patient  is  already  suiFeriug  will  be  aggra- 
vated. But  since,  as  in  the  case  of  the  threadworm,  the  appear- 
ance of  the  worm  itself  is  the  only  reliable  symptom,  it  is  most 
"unjustifiable  to  subject  a  child  to  a  long  course  of  worm  medicines 
on  suspicion  alone.  If  the  worm  real!}'  exist  in  the  intestine,  it 
will  soon  be  discharged  in  the  motions  after  a  few  days  of  treat- 
ment. It  must  be  remembered  that  in  cases  of  round-worm  some 
morbid  condition  of  the  intestinal  mucous  membrane  very  often 
pre-exists. 

Treatment. — Prophylaxis  is  more  important  and  more  efficacious 
in  the  management  of  disorders  caused  by  this  parasite  than  in 
cases  of  invasion  of  the  Oxyuris^  for  the  round-worm  always 
appears  to  be  introduced,  as  an  egg,  in  water,  whether  taken  pure 
or  with  raw  food  washed  for  the  table.  As  for  cure,  the  physi- 
cian, knowing  that  these  parasites  often  do  little  harm,  must  not 
forget  that  Davaine  has  recorded  several  fatal  cases  where  a 
round-worm  has  found  its  way  through  the  glottis  during  a  fit  of 
vomiting.  JSIoreover,  the  reflex  results  of  the  presence  of  the 
parasites  induce  dirty  habits,  such  as  picking  of  the  nose  or 
scratching  the  anus. 

By  far  the  best  remed}^  for  the  round-worm  is  santonin.  From 
■one  to  six  grains  should  be  given  to  a  child,  according  to  age ;  it 


INTESTINAL  WORMS. 


307 


may  be  administered  in  a  powder  mixed  with  sugar,*  or  as  the 
compound  scammony  powder. f  Dr.  Eustace  Smith  speaks  highly 
of  santonin  in  the  form  of  confection.:};  It  is  advisable  to  follow 
up  its  administration  by  a  dose  of  castor  oil,  and  then  to  give 
tonics,  particularly  steel  wine,  or  the  mineral  acids  with  some 
bitter  infusion.  I  am  in  the  habit  of  giving  the  santonin  every 
other  night  for  about  four  nights,  and  daring  the  day  a  tonic  of 
iron,  arsenic,  or  quinine.  I  sometimes  combine  these  three  reme- 
dies together,  but  I  am  generally  content  with  the  two  first 
(Form.  93).  The  persistence  of  the  parasite  after  long  treatment 
will  most  likelj^  be  due  to  the  neglect  of  prophylactic  measures, 
such  as  a  careful  examination  into  the  water-supply  and  the  sani- 
tary measures. 

Another  nematode,  TrichocejoJialiis  dispar,  infests  the  caecum  and 
colon.  It  measures  over  an  inch  in  length,  and  the  anterior  part 
of  its  body  is  filiform,  the  posterior  being  much  stouter.  It  is 
remarkable  for  producing,  as  a  rule,  no  symptoms  of  irritation, 
and  it  is  only  recognized  in  lifetime  by  the  appearance  of  its  ova 
in  great  quantity  in  the  fseces.  It  may  be  expelled  by  doses  of 
santonin,  or  active  aperients. § 

Tapeworm. — The  tsenise  are  Scolecida,  arranged  in  a  distinct 
order  very  different  from  the  nematodes.     Their  anatomy  is  very 


at  bedtime. 


Pulv.  jalapse, 
Sulphuris  loti, 
Conf.  Sennee, 


3j  tliree  times  a  day. 


gr.  iv-vj 


*  Formula  48: 

R.    Santonin, 
Saccbari, 

Fiat  pnlvis.    To  be  taken  every  third  night. 
t  Formula  49 : 

li.    Santonin,     ..... 
Pulv.  scaramonii  co.,   . 

Fiat  pulvis.      To  be  taken 
X  Formula  50 : 

R.    Santonin, 

Pulv.  zingib., 


gr.  V. 


gr.  XV 

gr.  V 

3ss. 

5J--M. 


?  The  practitioner  wishing  to  identify  a  parasite  which  he  believes  to  be  Tricho- 
cephalus  clispur,  will  find  specimens  (Nos.  8(3  and  87)  in  the  collection  of  Entozoa  at 
the  Museum  of  the  Eoyal  College  of  Surgeons,  arranged  by  Dr.  Cobbold. 


308  DISEASES   OF    CHILDEEN. 

complicated,  and  their  method  of  propagation  has  ah'eady  been 
described  in  the  chapter  on  "  Hydatid  Diseases."* 

"  The  tseniaf  is  rare  in  childhood  ;  in  206  of  Wawruch's  cases, 
22  were  children  under  fifteen  years  of  age,  the  youngest  was  3| ; 
Legendre  {Archives  Generale  de  3Jedecine,  vol.  iv,  p.  642)  has 
collected  from  different  authorities  26  cases  of  tapeworm  in  chil- 
dren under  twelve.  (In  children  from  fourteen  to  fifteen  months 
of  age,  2  cases  ;  two  years  old,  1  case  ;  three  years  old,  2  cases ; 
four  years  old,  2  cases;  five  years  old.,  3  cases;  six  years  old,  3 
cases  ;  seven  years  old,  4  cases ;  eight  and  nine  years  old,  1  case  ; 
ten  years  old,  2  cases;  eleven  years  old,  4  cases;  twelve  years  old, 
1  case.)  Hufeland,  quoted  by  M.  Davaine,  has  seen  an  infant  six 
months  old,  and  at  the  breast,  subject  to  tapeworm;  'on  different 
occasions  he  passed  up  to  twenty  meters  (over  sixty-five  feet)  of 
tasnia,  sans  accident  retentissant  sur  sa  sante."^ 

The  treatment  will  be  similar  in  childhood  to  that  adopted  for 
adults.  The  remarkable  words  which  we  have  left  in  their  origi- 
nal language  at  the  close  of  the  above  quotation  fortunately  apply, 
at  least  to  a^  great  extent,  to  most  cases.  The  extract  of  male- 
fern  is  as  efiicacious  in  the  young  as  in  the  old.  It  is  a  good  plan 
to  see  that  the  bowels  are  effectually  emptied  before  beginning 
the  specific  treatment,  and  to  attain  this  end  a  mild  aperient 
should  be  given  occasionally,  and  the  diet,  for  a  few  days,  ought 
to  consist  only  of  milk  and  beef  tea.  When  the  attempt  is  made 
to  dislodge  the  parasite  a  dose  of  castor  oil  should  be  given  at 
night,  and  the  oil  of  male-fern  early  on  the  following  morning.:]: 
Foreign  writers  prefer  pomegranate  and  kousso  for  children. 
Goubert  gives  15  grams  (equivalent  to  231  grains)  of  pomegran- 
ate-root-bark,  in   decoction,   to   children  under   five,  and    20.40 

grams  for  a  child  from  six  to  twelve,  in  750  grams  of  water, 

t . 

*  The  Mnseuni  of  the  College  of  Surgeons  contains  numerous  specimens  of  the  beef 
tapeworm  {T.  mediocanellaia) .     One  of  these  is  from  a  little  girl  (Entozoa  series,  No. 
116).     This  is  much  nioi-e  common  than  the  pork  tapeworm  {T.  solium).    Dr.  Cobbold 
estimates  tlie  jij-oportion  in  England  at  94  per  cent,  in  favor  of  the  former  species, 
f  (jroubert,  op.  cit. 
J  Formula  51 : 

R.  Ext.  filicis  li(}uid., J5ss.-3j 

Syr.  zingib. .         .     3,j 

Pulv.  acaciae,  .........     gr.  x 

Afpiam  cinnamoni  ad ^j. — M. 

Fiat  haustus.     For  a  child  from  five  to  ten  years  old. 


INTESTINAL   WORMS.  309 

to  be  taken  in  three  doses  at  intervals  of  half  an  hour,  followed 
by  castor  oil  if  the  parasite  be  not  passed  within  six  hours. 

The  exotic  and  rarer  parasites  hardly  come  within  the  scope  of 
this  work.  But,  in  conclusion,  a  few  general  remarks  may  be 
made  on  the  symptoms  which  worms  are  capable  of  producing, 
and  how  difficult  it  is  sometimes  to  form  a  diagnosis. 

Symptoms  of  an  obscure  and  deceptiv^e  character,  which  cannot 
be  classified  under  any  definite  disorder,  and  which  vary  from  day 
to  day,  are  frequently  cleared  up  by  the  discovery  of  worms. 
Lurking  mischief  in  the  lung  or  brain  has  been  apprehended  in 
some  cases,  or  the  approach  of  fever  has  seemed  imminent  in 
others.  Fits  of  passion,  violent  screaming,  restless  sleep,  and  even 
fits  of  epilepsy  or  chorea,  have  been  ascertained  to  depend  upon 
these  parasites  in  the  intestines,  and  the  symptoms  have  been 
found  to  pass  away  on  their  expulsion.  A  child  so  affected  loses 
its  animation,  and  is  languid  and  out  of  sorts  ;  it  suflTers  from 
headache,  and  its  temperature  is  high  in  the  evening.  This  has 
been  known  to  reach  103°,  or  more.  The  child  becomes  weak  and 
thin,  and  ceases  to  thrive ;  the  appetite  is  capricious,  and  it  some- 
times refuses  almost  any  kind  of  food  that  is  offered,  while  at 
others  it  is  quite  ravenous  ;  the  eyes  are  dark  and  hollow,  the 
tongue  is  furred,  and  there  is  sometimes  a  dry  hacking  cough, 
which  makes  parents  anxious,  although  they  are  assured  that  no 
lesion  in  the  lungs  can  be  discovered.  Such  cases  are  often  ascribed 
to  commencing  tubercular  mischief  in  the  lungs  or  brain,  and  the 
best  observers  have  been  misled  in  their  di§,gnosis.  The  cough 
being  the  result  of  intestinal  irritation  the  child  recovers  its  usual 
health  as  soon  as  the  worms  are  removed. 

These  symptoms  are  very  treacherous,  and  they  continue  so 
obstinate  in  some  cases  that  only  time  can  clear  up  their  true 
meaning.  They  may  simulate  brain  disease  by  the  occurrence  of 
a  convulsion  followed  by  squinting.  Vogel  mentions  the  case  of 
a  child  who  was  attacked  by  convulsions,  and  a  few  days  after 
with  all  the  symptoms  of  acute  hydrocephalus,  followed  by  death 
in  a  few  hours.  On  a  post-mortem  examination,  the  brain  and 
all  the  internal  organs  were  found  in  a  perfectly  healthy  state, 
"  but  in  the  intestinal  canal  there  were  more  than  a  hundred 
round-worms,  rolled  up  in  small  and  large  balls,  at  some  points 
completely  choking  up  the  calibre  of  the  canal ;  the  mucous  mem- 
brane itself  in  the  same  regions  had  become  reddened."* 

*  Diseases  of  Children,  1871,  p.  207. 


310  DISEASES    OF    CHILDREN". 

CHAPTER   XXVIII. 

DISEASES    OF    THE   NASAL    CAVITIES. 

CoRYZA — Nasal  Catarrh  (Common  Cold,  or  Cold  in  the  Head)  :  Nature — 
Causes — Pathology — Symptoms — Treatment.  Oz^na:  Nature — Causes — 3  Forms. 
1.  Scrofulous    Oz^na.    2.  Syphilitic    Oz^na.      3.   Traumatic    Oz^na  : 

Siimptoms — Treatment.  Epistaxis:  Nature — Causes — Treatment.  Laryngeal 
and  Tracheal  Irritation  in  Young  Children  :  Symptoms  and  causes — 
Diagnosis  from  croup — Local  and  general  treatment. 

The  entire  mucous  membrane  in  infancy  and  childhood  is  prone 
to  morbid  action,  commencing  at  the  mouth  or  nostrils,  and  fre- 
quently exciting  catarrh,  not  only  in  the  larynx  and  air-passages, 
but  in  the  intestinal  tract  also. 

The  mucous  membrane  of  the  nose  is  liable  to  hypersemia,  in- 
flammation, and  tumefaction. 

Coryza,  or  cold  in  the  head,  is  a  common  ailment,  and  is  fre- 
quently observed  in  delicate  and  strumous  children.  It  is  most 
common  in  winter,  but  it  may  occur  at  all  seasons  of  the  year. 
It  may  be  associated  with  bronchitis,  laryngeal  catarrh,  measles, 
whooping-cough,  etc. 

Causes. — These  are  exposure  to  cold  when  the  surface  becomes 
chilled.  There  is,  according  to  Eosenthal,  a  heat-producing  area 
and  a  heat-radiating  area,  and  when  a  loss  of  balance  takes  place 
between  the  two,  a  chill  to  the  surface  brings  about  this  frequent 
ailment.  If  heat-loss  and  heat-production  are  equivalent,  no  harm 
results  from  exposure.  Whenever  a  person  is  exposed  to  cold,  the 
cutaneous  vessels  undergo  contraction,  so  that  the  blood  accumui- 
lates  in  the  internal  organs,  and  more  animal  heat  is  evolved  than 
is  usual.  Hence  a  child  more  easily  catches  cold  if  it  is  not  suffi- 
ciently protected  hy  proper  clothing,  or  the  temperature  of  the 
rooms  in  which  it  lives  and  sleeps  is  too  low.  When,  on  the  other 
hand,  the  atmosphere  of  the  room  is  too  hot,  or  active  exertion  is 
undertaken  in  it,  so  as  to  induce  free  perspiration,  the  vessels  of 
the  skin  dilate,  and  animal  heat  is  freely  given  olF.  The  vaso- 
motor nerves  of  the  vessels  of  the  air-tubes  become  partially  para- 
lyzed, and  hence  a  catarrhal  state  is  easily  set  up.  If  now,  as 
often  happens,  the  child  exposes  itself  to  a  draught  of  cold  air,  or 
goes  into  an  apartment  that  is  many  degrees  too  low,  then  the 
vessels  which   are  dilated  lose  their  power  to  contract,  and  the 


DISEASES   OF   THE   XASAL   CAVITIES.  311 

blood,  instead  of  passing  freely  through  them  as  before,  stagnates 
in  them,  or  accumulates  in  the  deeper  tissues  or  organs  of  the  body. 
All  the  morbid  elements,  instead  of  finding  an  outlet  through  the 
skin,,  accumulate  in  the  blood,  to  the  detriment  of  the  imtient's 
general  nutrition.  If  the  atmospheric  air  inhaled  at  the  same 
time  be  not  pure,  another  evil  is  added  ;  the  lungs,  like  the  skin, 
do  not  part  with  a  sufficient  quantity  of  carbonic  acid,  and  the 
condition  of  cold  may  lead  to  some  more  serious  state.  Every 
case  is  not  equallj^  severe.  When  the  blood  is  only  slightly  con- 
taminated with  refuse  products,  the  cutaneous  vessels,  after  mod- 
erate dilatation,  soon  resume  their  normal  calibre,  and  a  cold  is 
either  avoided  altogether,  or  it  is  very  transient  in  duration. 

Living  in  rooms  above  a  temperature  of  Q5°  predisposes  to  cold 
by  weakening  the  system.  "  There  are  few  causes  which  promote 
susceptibility  to  cold  so  much  as  sleeping  in  close  rooms  ;  the  blood 
being  thus  charged  with  carbonic  acid  and  other  foul  gases  is  prone 
to  stagnate,  and  thus  congestion,  the  first  step  to  catarrhal  inflam- 
mation, occurs."" 

Local  irritation  arising  from  fog  and  mist,  the  entrance  of  dust 
into  the  nostrils,  air  laden  with  pollen  from  hay,  and  repeated 
blowing  of  the  nose,  are  all  excitants  of  nasal  catarrh. 

The  most  intense  nasal  catarrh  is  sonietimes  induced  by  taking 
a  few  grains  of  iodide  of  potassium.  I  myself  suffered  from  sleep- 
lessness and  severe  pain  across  the  frontal  sinuses,  with  great  irri- 
tation of  the  lining  membrane  of  the  nose,  and  a  peculiar  sensation 
of  fulness  and  tightness  across  the  forehead,  in  consequence  of 
taking  this  drug.  The  discomfort  was  so  peculiar  and  severe, 
that  I  never  before  experienced  anything  at  all  like  it  from  the 
most  severe  catarrh. 

Pathology. — The  capillaries  are  swollen  and  engorged  with  blood, 
producing  hyperemia  and  congestion  of  the  mucous  membrane. 
This  furnishes  an  acid,  saline,  and  watery  secretion,  which  inflames 
and  even  excoriates  the  lips.  In  severe  cases,  the  submucous  tis- 
sues are  infiltrated,  and  the  pharyngeal  glands  are  enlarged,  or 
even  ulcerated.  As  the  swelling  of  the  mucous  membrane  dimin- 
ishes, the  discharge  becomes  thicker  in  consistence,  and  even  puru- 
lent in  character. 

As  to  the  possible  contagion  of  catarrh,  it  cannot  be  denied  that 
the  frequency  with  which  colds   run  through  a  household  seems 

*  Colds  and  Coughs,  by  E.  Symes  Thompson,  M.D.,  1877,  p.  26. 


312  DISEASES   OF   CHILDEEN. 

to  prove  that  those  who  sufier  may  by  contact  impart  it  to  the 
healthy.  Using  the  same  pockethandkerchief  ma}^  become  an- 
other medium  of  conveyance.  The  contagions  principle  given 
ofl"  by  sneezing  or  coughing  may  excite  irritation  in  a  healthy 
mucous  membrane,  and  produce  catarrh. 

Symptoms. — The  earliest  sjnuptoms  are  those  of  dryness  and 
titillatiou,  with  the  sensation  of  obstruction  in  the  nostrils,  which 
induces  a  disposition  to  blow  the  nose  frequently.  This  is  accom- 
panied with  sneezing  and  pain  across  the  frontal  sinuses,  or  even 
headache  ;  the  voice  is  thick  and  nasal,  the  conjunctivae  are  in- 
jected or  inflamed,  and  tears  run  down  the  cheeks ;  if  the  discom- 
fort is  so  great  that  there  is  much  blowing  of  the  nose,  considerable 
epistaxis  may  result ;  the  larynx  may  be  involved,  inducing  sore- 
ness and  hoarseness,  whilst  the  catarrh  may  extend  up  the  Eus- 
tachian tube,  producing  deafness  and  singing  in  the  ears.  There  is 
more  or  less  febrile  disturbance,  loss  of  appetite,  and  thirst. 

A  large  number  of  cases  of  incurable  deafness,  chronic  conjunc- 
tivitis, and  lachrymal  disease  have  been  traced  to  frequent  attacks 
of  coryza.* 

Treatment. — When  an  acute  catarrh  is  developed  with  febrile 
disturbance  and  running  of  the  nose,  confinement  to  bed  in  a  warm 
room,  fluid  food,  and  diluents  will  be  necessary  to  encourage  dia- 
phoresis, and  so  relieve  the  internal  organs  from  mischief.  A 
warm  linseed  poultice  covering  the  entire  chest  is  often  comforting 
and  beneficial.  Ipecacuanha,  small  doses  of  tartarated  antimony 
with  liquor  ammonite  acetatis  (Form.  7)  will  be  suitable ;  while  a 
saline  aperient  (Form.  8)  will  cool  the  sj'stem,  and  bring  down  the 
fever.  A  pleasant  cooling  drink  may  be  made  b}^  adding  one  tea- 
spoonful  of  acid  tartrate  of  potash  (cream  of  tartar)  to  a  pint  of 
barley-water,  sweetened  and  flavored  with  lemon-juice.  It  acts  as 
a  refrigerant,  diuretic,  and  aperient.  A  correspondent  speaks 
highly  of  full  doses  of  the  tincture  of  belladonna  night  and  morning 
in  severe  coryza.  Two  doses  generally  complete  the  cure.  As 
children  bear  this  drug  so  well  it  may  be  given  in  suitable  cases.f 
Fruit  lozenges,  and  lozenges  of  Iceland  moss  and  chlorate  of  potash 
are  demulcent,  and  encourage  secretion.  Morphia  and  other  seda- 
tives require  to  be  given  with  great  care  to  children,  for  by  arrest- 

*  Brit.  Med.  Jour.,  vol.  i,  1S80,  p.  490. 
t  lb.,  vol.  i,  1877,  p.  220. 


DISEASES   OF   THE   NASAL   CAVITIES.  313 

iiig  secretion  they  may  increase  the  congestion  of  the  mucous 
membrane,  and  derange  the  health. 

•  Ozcena. — The  mucous  membrane  of  the  nose  is  also  liable  to  an 
eezematous  or  ulcerating  surface,  from  which  a  thick,  irritating 
discharge  escapes.  The  mucous  membrane  is  thickened  and  con- 
gested, as  in  ordinary  catarrh.  This  is  followed  by  the  drying  up 
of  the  secretion  into  thick  crusts,  which  almost  close  the  nasal 
cavities,  and  become  a  source  of  great  annoyance  to  the  child. 
"When  these  crusts  are  removed  the  surface  is  found  ulcerated  be- 
neath. 

"  In  many  instances  we  find  the  posterior  wall  of  the  pharynx 
covered  with  similar  crusts."*  The  discharge  is  muco-purulent 
and  bloody,  escaping  from  one  or  both  nostrils,  highly  offensive  in 
odor,  tedious  in  duration,  and  difiicult  of  cure.  When  the  patient 
lies  down  the  discharge  may  trickle  into  the  larynx,  and  set  up 
congestion  and  irritation  there. 

The  leading  feature  of  ozfena  is  intense  fetor  of  the  breath. 
The  discharge  may  be  too  oflensive  for  the  patient  to  go  into 
society,  and  yet  the  nasal  bones  remain  unaffected.  When  the 
discharge  is  of  this  character  w^e  may  suspect  that  diseased  bone 
is  at  the  root  of  the  evil.  There  is  sometimes  burning  and  throb- 
bing pain  in  the  nostrils,  and  the  integumental  covering  of  the 
nose  is  red  and  swollen  when  the  discharge  does  not  freely  escape. 

Causes. — These  discharges  are  met  with  in  delicate  children, 
and  not  unfrequently  follow  tedious  catarrh  or  the  eruptive  fevers, 
as  measles  and  scarlet  fever.  Oz?ena  may  be  associated  with 
syphilis  and  scrofula.  A  blow  on  the  nose  may  act  as  an  exciting 
cause. 

Mr.  Warrington  Haward,  in  an  excellent  paper  on  oztena,  from 
which  I  have  gathered  much  information  for  this  article,  classifies 
the  disease  under  three  principal  heads  :  1.  Scrofulous  ozpena.  2. 
Syphilitic  ozsena.  3.  Traumatic  ozpena.  He  also  mentions  an 
"idiopathic  ozpena"  not  referable  to  either  of  the  above  causes. f 

1.  Scrofulous  Ozffna. — A  large  number  of  cases  of  ozfena  appear 
to  arise  from  scrofula  in  children.  The  skin  and  mucous  mem- 
branes are  especially  liable  to  be  affected  in  this  diathesis,  and 
hence  we  see  troublesome  eczema,  strumous  ophthalmia,  otorrhoea, 
bronchial  affections,  and  chronic  diarrhcea.     Children  with  this 

*  Niemeyer's  Textbook  of  Practical  Medicine,  1875,  vol.  i,  p.  290. 
t  St.  George's  Hospital  Reports,  1874-1876,  p.  130. 


314  DISEASES    OF    CHIEDEE^■. 

constitutional  taint  suffer  from  enlarged  cerv,ical  glands,  whieh 
sometimes  ulcerate  and  are  slow  to  heal.  The  nasal  mucous  mem- 
brane is  thickened  and  swollen,  and  pustules  and  small  round 
ulcers  are  seen  on  the  lining  membrane.  This  form  of  scrofula  is 
often  accompanied  by  troublesome  eczema  (Haward).  The  horri- 
ble fetor  of  ozfena  is  owing  to  the  discharge  being  either  pent  up 
in  a  cavity  from  which  it  cannot  escape,  and  therefore  it  decom- 
poses, or  to  the  presence  of  a  piece  of  dead  bone.  In  the  latter 
case  no  antiseptic  injection  will  be  of  any  service  till  the  necrosed 
bone  has  been  removed. 

2.  SyphUiiic  Ozcpjia. — Syphilis  is  the  next  most  common  cause 
of  ozffiua,  of  which  there  are  symptoms  not  to  be  mistaken.  The 
ulcers  are  superficial  or  deep,  excavated  and  sloughing ;  they  are 
larc^er,  fewer  in  number,  and  more  irregular  in  outline  than  in  the 
preceding  variety.  A\'hen  the  bone  becomes  affected  the  discharge 
is  most  offensive. 

'6.  Trauraaiic  ozcEna  is  the  result  of  injury  to  the  nose,  or  of  the 
presence  of  some  foreign  body.  This  sets  up  periostitis,  followed 
by  necrosis  of  the  bone,  and  the  cure  depends  upon  its  removal. 
In  children,  peas,  beans,  bits  of  wood  or  pencil  are  sometimes 
thrust  up  the  nose,  giving  rise  to  inflammation  and  ulceration  of 
the  mucous  membrane.  If  the  offending  body  is  removed  before 
the  bone  is  diseased,  the  discharge,  which  depends  on  a  local  cause, 
usually  soon  ceases. 

"  IdiojMthic  ozcena,''  according  to  Mr.  Haward,  seems  to  fre- 
quently follow  scarlatina  and  measles.  In  my  own  experience  a 
very  severe  case  of  ozEena  followed  measles  in  a  child  who  had  no 
constitutional  taint.  A  thin,  semi-purulent,  and  sometimes  gleety 
discharge  continued  for  many  weeks,  but  ultimately  ceased.  The 
nasal  mucous  membrane  was  red  and  swollen,  and  easily  bled  on 
examination  or  blowing  the  nose. 

When  purulent  matter  is  pent  up  in  the  sinuses  there  is  severe 
frontal  headache  and  sleeplessness  at  night.  Cases  are  mentioned 
where  the  discharge  has  found  its  way  into  the  cranium,  or  the 
sinus  has  become  so  distended  that  it  has  encroached  on  the  orbit 
and  displaced  the  eyebalL 

Treatment. — With  the  aid  of  the  laryngoscope,  the  nasal  cavi- 
ties, previously  washed  out  by  means  of  the  nasal  douche,  can  be 
well  examined.  Mr.  Haward  also  recommends  that  the  nostrils 
be  dilated  by  Fraenkel's  speculum,  which  he  says  is  the  best. 


DISEASES   OF   THE   NASAL   CAVITIES.  315 

^  In  the  treatment  of  scrqfaloas  ozcena,  the  general  health  must 
be  attended  to.  Cod-liver  oil,  steel  wine,  the  ammonio-citrate  of 
iron,  or  reduced  iron,  will  be  necessary.  The  nasal  cavities  may- 
be washed  out  frequently  with  a  solution  of  common  salt  (half  an 
ounce  to  a  pint  of  slightly  warm  water),  or  tincture  of  myrrh  oij, 
chlorate  of  potash  5ij  to  a  pint  of  water,  or  5ij  of  Condy's  fluid  to 
a  pint  of  water.     Sea  air  is  of  the  greatest  utility. 

In  the  treatment  of  s^phUitm  ozcena  mercury  must  be  emploj-ed, 
and  the  best  mode  of  using  it,  according  to  Mr,  Haward,  is  the 
calomel  vapor-bath,  recommended  by  Mr.  Henry  Lee.  Ilyd.  c." 
creta  for  children  is  valuable,  whilst  iron,  bark,  cod-liver  oil,  and 
iodide  of  potassium  are  to  be  given  at  the  same  time.  As  a  local 
application,  when  the  bone  is  not  affected,  Mr.  Haward  recom- 
mends an  ointment  of  fifteen  or  twenty  grains  of  red  oxide  of 
mercury,  and  olive  oil  and  lard,  of  each  half  an  ounce.  After 
syringing  with  the  nasal  douche,  this  should  be  applied  with  a 
brush.  He  also  speaks  well  of  the  ammonio-chloride  of  mercury 
ointment,  with  olive  oil. 

In  the  treatment  of  the  traumatic  form^  antiseptic  washings  will 
be  needed,  and  the  necrosed  bone  must  be  removed  if  present. 

For  the  management  of  the  idiopathic  forms^  the  general  health 
will  require  attention,  and  the  application  from  time  to  time 
of  a  lotion  of  chlorate  of  potash  and  myrrh.  Glycerin  of  tannic 
acid  and  dilute  mercurial  ointment  are  also  useful  in  some  cases. 

Carbolic  acid  has  been  found  very  serviceable  in  ozcena,  and  in 
other  discharges  from  the  nose  and  throat.  All  mucus  should  be 
first  cleared  from  the  afiected  parts  by  a  weak  alkaline  solution, 
and  then  carbolic  acid  (1  in  4:0)  should  be  injected  along  the  floor 
of  the  nostrils,  or  into  the  pharynx,  as  the  case  may  be.* 

A  diluted  tincture  of  iodine  (1  in  30)  may  be  sometimes  injected 
into  the  nostrils  with  advantage. 

In  chronic  ozsena,  where  the  mucous  membrane  is  in  a  relaxed 
and  weak  condition,  twenty  to  thirty  grains  of  alum,  added  to 
eight  ounces  of  water,  form  an  excellent  application.  It  should 
be  injected  up  the  nostrils  with  a  bottle  syringe,  or  one  end  of  an 
elastic  tube  may  be  inserted  in  a  basin  containing  the  solution,  at 
a  proper  height,  and  the  other  placed  in  the  nostril.  If  the  head 
is  bent  forward  and  the  mouth  kept  open,  the  fluid  will  permeate 

*  Brit.  Med.  Jour.,  1869,  vol.  i,  p.  145. 


316  DISEASES   OF   CHILDRE^^. 

the  nasal  cavit}'  and  run  out  of  tlie  other  nostril.  Carbolic  acid 
is  preferable  where  there  is  much  fetor. 

Mr.  Pugin  Thornton  recommends  a  cold  lotion*  to  be  injected 
daily  up  the  nostrils  by  means  of  a  hand-ball  spraj^  apparatus. 
He  says  it  has  succeeded  in  very  obstinate  cases,  after  the  inhala- 
tion of  camphor,  benzoin,  and  carbolic  acid  had  failed.  Eight  or 
ten  applications  have  cured  the  most  obstinate  cases.f 

Glycerin  of  tannin  is  another  application,  particularly  useful 
in  syphilitic  ozpena.  Iodide  of  potassium  may  be  cautiously  given, 
but  small  doses  of  mercury  with  bark  or  iron  in  such  a  case  would 
be  preferable,  as  this  salt  so  often  induces  nasal  irritation. 

Nitrate  of  silver  (gr.  v  ad  .5J)  is  serviceable  where  the  mucous 
membrane  is  swollen,  and  the  complaint  seems  within  reach. 

In  those  cases  that  resist  all  medical  treatment,  a  surgical 
operation  may  become  necessary. 

JEpistaxis  is  the  most  common  form  of  spontaneous  hsemorrhage, 
arising  in  all  likelihood  from  the  slender  resistance  which  the 
walls  of  the  vessels  afford  to  tbe  force  of  the  blood-current.  The 
rupture,  too,  in  many  instances,  probabl}''  depends  upon  a  morbid 
state  of  the  capillary  walls  or  the  hsemorrhagic  diathesis. 

Among  the  causes  which  predispose  to  this  affection  are  catarrh 
and  whooping-cough,  tuberculosis,  disease  of  the  spleen,  and  the 
exanthemata.  A  blow  or  fall  on  the  nose  may  excite  bleeding  at 
once.  One  of  the  worst  cases  I  ever  saw  was  tbat  of  a  girl  suffer- 
ing from  typhoid  fever,  where  the  blood  had  become  thin  and 
deteriorated.  Plugging  of  the  posterior  nares  was  required  to 
arrest  the  profuse  bleeding ;  the  patient  bled  from  the  bowels  and 
urinary  tract  at  the  same  time,  and  the  body  was  covered  with 
hsemorrhagic  spots  (petechiEe). 

Epistaxis  is  rarely  seen  in  very  young  children  or  in  those  who 
are  strong  and  well  developed.  It  is  most  common  in  the  delicate, 
who  have  weak  muscles  and  thin  bones.  The  blood  may  flow 
from  one  or  both  nostrils,  either  in  drops  or  a  full  stream.  If  the 
haemorrhage  should  happen  during  sleep,  the  blood  flows  back 
into  the  pharynx,  and  excites  cough  if  it  gets  into  the  larynx,  or 

*  R.  Sodse  carb., 

Sodse  bihorat.,  aa gij 

Liq.  sodpe  clilorinatse, 35s.-3ij 

Glycerini, 5j 

Aquam  ad     .         . S^'iij- — M. 

t  The  Treatment  of  Ozseaa,  Brit.  Med.  Journ.,  1880,  vol.  i,  p.  475. 


DISEASES   OF   THE   NASAL   CAVITIES.  317 

vomiting  if  it  goes  into  the  stomach.  If,  as  often  happens,  coagu- 
lation takes  place  quickly,  the  hoemorrhage  is  speedily  checked; 
but  if  the  bIood_he  thin,  the  tendency  to  coagulation  is  so  slight 
that  the  patient  may  bleed  till  the  lips  and  face  are  pallid,  the 
conjunctivfB  blanched,  and  the  skin  is  of  waxy  whiteness.  After 
continued  and  great  loss  of  blood,  the  heart  becomes  weak  and 
irritable,  there  is  faintness  and  prostration,  the  surface  is  damp 
and  sweating,  there  is  restlessness,  headache,  and  even  delirium. 

Treatment. — Absolute  rest  in  bed, in  a  semi-erect  posture,  should 
be  observed  in  all  cases  of  nasal  hemorrhage  where  the  loss  is  con- 
siderable, and  the  eftects  of  the  drain  are  telling  upon  the  system. 
It  is  most  important  to  avoid  blowing  of  the  nose,  which,  how- 
ever, in  children  is  by  no  means  easy  to  prevent.  Holding  the 
nostrils  tightly  between  the  fingers,  and  applying  cold  to  the 
bridge  of  the  nose  will  stop  the  haemorrhage  in  most  cases.  If 
this  fail,  the  injection  of  iced  water  up  the  nostrils  with  an  ordi- 
nary bottle  syringe  maj^  prove  eflectual.  The  introductiou  of 
powdered  alum,  or  ox-galls  has  sometimes  succeeded.  Internally, 
gallic  acid,  sulphuric  acid,  tincture  of  the  perchloride  of  iron,  and 
ergot  will  be  suitable  remedies.  Sir  T.  Watson  mentions  the  sim- 
ple'expedient  of  the  patient  raising  one  or  both  arms  above  his 
head,  and  of  maintaining  them  in  this  position  for  some  time.* 
In  cases  which  resist  all  ordinary  treatment,  we  must  have  re- 
course to  the  unpleasant  operation  of  plugging  the  posterior  nares. 

Laryngeal  and  Tracheal  Irritation  in  Young  Children. — No  sooner 
is  the  respiratory  apparatus  called  into  play  than  it  becomes  liable 
to  disease,  and  it  remains  so  from  infancy  to  old  age,  especially  in 
this  variable  climate.  We  have  recorded,  on  the  authority  of 
Orfila,  Cruveilhier,  and  others,  that  traces  of  inflammation  and  its 
products  are  even  sometimes  met  with  in  the  bronchial  tubes  and 
structure  of  the  lung  during  fetal  life.  "The  great  transition," 
says  Dr.  Churchill,  "from  the  atmosphere  of  uterine  life  to  the 
severe  and  changeable  atmosphere  of  extrauterine  existence, 
renders  the  infant  peculiarly  susceptible."  Exposure,  as  in  dress- 
ing, to  draughts  of  cold  air,  readily  excites  the  mucous  membrane 
of  the  air-passages,  which  becomes  vascular,  tender,  and  irritable. 
At  certain  seasons  of  the  year,  when  the  thermometer  is  lower 
than  usual,  affections  of  the  breathing  organs  are  very  common 
among  young  children. 

*  Principles  and  Practice  of  Medicine,  4th  edit.,  vol.  i,  p.  795. 


318  DISEASES   OF   CHILDREN. 

Bronchitis,  croup,  pneumonia,  arising  from  cold  or  as  a  sequence 
of  scarlatina  and  measles,  come  constantly  before  us ;  but  there  is 
a  condition,  not  expressed  by  either  of  these  terms,  which  is  apt  to 
be  overlooked,  from  the  absence  of  marked  physical  and  general 
signs,  and  from  the  insidious  manner  in  which  it  commences  and 
steals  on.  This  condition  is  at  first  one  of  purely  local  irritation, 
occupying  the  larynx  and  trachea,  neither  extending  to  the 
pharynx  and  tonsils  nor  into  the  bronchial  tubes. 

A  ver}^  conmion  mode  of  its  commencement  is  the  following: 
The  nurse  observes  that  the  child  (probably  from  one  to  two  years 
old)  is  quite  well,  with  the  exception  of  a  slight  cold,  but  there  is 
no  cough  or  other  disturbance  of  the  system  ;  all  the  functions  are 
regular,  and  the  child  sleeps  well ;  it  perhaps  looks  pallid,  and  the 
nostrils  and  upper  lip  are  red,  caused  by  frequent  wiping  of  the 
nose,  as  in  older  children  and  adults  when  euftering  from  catarrh. 
This  state  of  things  goes  on  for  several  days,  and  if  the  weather 
should  become  mild,  the  child  goes  out  of  doors  as  in  health,  and 
the  cold — for  it  seems  no  more — passes  away.  Should  circum- 
stances, however,  prove  unfavorable,  these  symptoms  are  soon 
succeeded  by  a  short,  shrill,  barking  cough,  unattended  by  the 
prolonged  inspiratory  eiibrt  of  croup  and  laryngismus  ;  the  pulSe  is 
quiet,  and  there  is  no  fever.  If  the  medical  attendant  is  consulted 
at  this  stage  he  observes  nothing  of  importance,  the  muscles  of  the 
larynx  and  neck  are  tranquil,  and  the  child  when  asleep  leans  his 
head  forward  on  his  chest.  The  nurse  will  tell  you  that  the 
cough  is  the  only  symptom  worth  notice  ;  that  it  wakes  the  child, 
and  makes  him  peevish  and  fretful — no  doubt  from  the  extreme 
tenderness  and  irritabiliry  of  the  membrane  involved.  The  chest 
is  clear  on  percussion,  and  there  are  no  moist  sounds  from  base  to 
apex.  The  affection  is  often  ascribed  to  teething,  and  on  looking 
into  the  mouth  the  gums  may  be  inflamed  from  the  pressure  of 
new  teeth.  Another  day  elapses,  and  perhaps  in  the  night  the 
child  starts  up  in  his  sleep,  flushed  and  excited,  with  one  or  both 
cheeks  red ;  the  skin  is  hot,  and  the  little  patient  is  irritable  and 
alarmed  ;  the  cough  is  louder,  more  barking,  and  resembles  croup ; 
the  respiration  is  not  quickened  in  proportion  to  the  pulse,  the  alse 
nasi  are  not  active,  nor  is  the  countenance  anxious  and  distressed, 
as  would  be  the  case  in  pneumonia  or  croup.  On  looking  into  the 
throat  no  redness  or  change  of  any  sort  can  be  observed.  As  the 
disease  creeps  on,  the  child  becomes  prostrate,  loses  appetite,  and 


DISEASES   OF   TPIE   NASAL   CAVITIES.  319 

will  not  leave  the  nurse's  arms  or  lie  down  in  bed.  If  you  apply 
the  ear  or  stethoscope  between  the  scapulae  at  the  upper  part,  you 
may  hear  a  little  crackling  at  each  inspiration,  or  slight  rhonchus; 
but  the  percussion-sound  is  clear  throughout  the  chest,  and  the 
respiration  is  normal  in  all  other  parts.  If  these  symptoms  are 
not  relieved,  genuine  bronchitis,  pneumonia,  or  convulsions  may 
supervene — conditions  favored  by  the  state  of  the  atmosphere  and 
the  constitution  of  the  patient. 

So  far  as  I  have  seen,  the  face  never,  at  any  period  of  the  com- 
plaint, assumes  that  bluish  tinge  from  imperfect  aeration  of  the 
blood  unless  these  complications  arise.  The  physiological  causes 
of  this  condition  must  be  ascribed  to  nervous  excitation ;  and  in 
very  young  children,  we  see  how  this  may  be  set  up.  The  trifacial 
nerve,  the  pneumogastric  nerve,  and  the  spinal  nerves  are  all  sepa- 
rately irritated  and  disturbed  in  their  functions  during  the  period 
of  dentition,  and  in  gastric  and  intestinal  disorder.  Under  the 
combined  influence  of  cold,  teething,  and  gastric  disturbance,  how 
easy  of  explanation  are  these  laryngeal  symptoms.  Now  croup  is 
the  disease  most  likely  to  be  confused  with  this  afiection,  and 
when  we  are  first  consulted  we  may  reasonably  pause  before  com- 
mitting ourselves  to  an  opinion ;  but  there  are  the  following  broad 
distinctions:  If  the  child  can  talk,  there  is  neither  hoarseness  nor 
huskiness  of  voice;  the  fever  is  never  high;  the  respiration  not 
perceptibly  hurried ;  the  cough  may  be  sudden,  convulsive,  and 
ringing,  but  the  crowing  inspiration  is  absent,  and  there  is  not  the 
restlessness  and  anxiety  of  croup,  nor  is  the  larynx  either  tender 
or  apparently  the  seat  of  uneasiness.  The  cough  and  expiratory 
bark  are  the  symptoms  of  all  others  that  resemble  croup ;  and,  at 
an  early  stage,  it  is  difficult  to  decide  on  the  disease  that  may  be 
about  to  spring  up ;  but  when  twenty-four  or  thirty  hours  have 
elapsed,  we  shall  have  very  little  difficulty.  When  this  condition 
has  lasted  a  few  days,  the  child  being  one  day  better  and  another 
worse,  you  may  almost  with  certainty  give  a  favorable  prognosis 
of  the  termination.  As  a  rule,  the  precursory  stage  of  croup  does 
not  last  beyond  a  day  or  two  ;  the  hoarse  voice  and  catarrhal  sjaiip- 
toms  being  rapidly  succeeded  by  more  marked  and  decided  proofs 
of  a  dangerous  disease. 

As  to  the  treatment  of  these  cases,  first  and  foremost  is  a  warm, 
moist,  and  equable  temperature,  not  lower  than  60°  Fahr.,  or  above 
70°.     In  the  acute  stage  of  genuine  croup,  it  might  be  necessary 


320  DISEASES   OF   CHILDREN. 

to  raise  the  temperature  of  the  apartment  higher  than  this.  The 
cases  under  consideration  are  less  acute  and  threatening,  and  it  is 
therefore  necessary  that  surrounding  influences  should  not  be  too 
exhausting.  If  there  is  a  choice  of  an  apartment  it  should  be 
large  and  airy,  and  candles  should  be  used  in  preference  to  gas  and 
lamps.  On  many  occasions  I  have  noticed  two  large  gas-burners 
in  small,  I'ow  nurseries  at  the  top  of  the  house,  where  one  or  two 
•children  with  their  nurse  are  living  through  the  day ;  so  that  the 
allowance  of  oxygen  for  each  person  must  be  very  limited,  and  cal- 
culated to  impair  the  general  health,  and  to  keep  up  rather  than 
subdue  the  tracheal  irritation.  On  removing  such  patients  to 
larger  and  better-ventilated  apartments  they  have  speedily  im- 
proved ;  but  it  is  necessary  to  maintain  a  moist  atmosphere,  and 
for  this  purpose  it  is  an  excellent  plan  to  place  a  Hat  kettle  on  the 
fire,  with  a  long  tube  projecting  above  the  guard  of  the  fireplace 
into  the  room.  At  the  end  of  the  tube  should  be  a  transverse  top, 
perforated  with  holes,  like  a  garden  flower-pot,  to  allow  the  steam 
to  escape  gradually.  Such  kettles  are  sold  by  Swan  JSTash,  in  Ox- 
ford Street,  under  the  name  of  "-Bronchitis  Kettles  ;"  in  all  cases 
of  croup  and  laryngeal  irritation  they  will  be  found  of  great  value. 
"Where  they  are  not  obtainable,  an  ordinary  kettle  of  water  should 
be  kept  boiling  on  the  fire;  and  even  a  hot  brick  or  fire-ball  should 
be  thrown  into  a  pan  of  hot  water.  This  keeps  up  warmth  and 
moisture  in  the  room,  and  soon  exerts  a  soothing  effect  on  the  ir- 
ritable membrane.  When  the  symptoms  are  urgent  and  the  cough 
distressing,  a  sponge  wrung  out  of  hot  water  and  kept  constantly 
applied  to  the  throat  will  give  relief.  Unless  the  management  be 
carefully  looked  after,  the  nurse  is  apt  to  make  the  child's  clothes 
wet,  and  even  to  neglect  the  application.  I  therefore  usually  em- 
ploy a  piece  of  rag  wetted  in  tepid  water,  and  apply  it  round  the 
throat  under  oil-silk.  This  is  both  a  convenient  and  good  remedy. 
Mustard  and  vinegar  poultices  to  the  throat,  strong  liniments,  and 
other  applications  of  a  stimulating  character  distress  and  irritate 
the  child,  and  are  not  to  be  thought  of.  If,  as  will  generally  be 
found,  the  stomach  and  bowels  are  not  satisfactorily  performing 
their  functions,  we  should  lose  no  time  in  applying  suitable  treat- 
ment. The  motions  are  often  scanty  and  light-colored,  sometimes 
containing  undigested  articles  of  food  ;  sometimes  of  a  greenish  hue 
and  highly  oftensive.  A  grain  of  calomel,  if  the  child  is  from  one 
to  two  years  old,  with  two  grains  of  jalapin  and  two  of  white 


\  DISEASES   OF   THE   XASAL    CAVITIES.  321 

sugar,  will  be  necessary,  and  this  will  usually  stir  up  the  liver 
and  small  intestines ;  after  a  free  action  of  the  bowels  the  breath- 
ing will  improve.  In  some  cases  I  have  seen,  the  breathing  has 
been  good  in  the  morning  and  the  child  has  appeared  lively, 
and  even  played  with  his  toys ;  but  towards  the  afternoon  and 
evening,  cough  has  come  on,  and  he  has  been  more  than  once  sick 
in  the  attempt  to  dislodge  a  little  glairy  mucus  from  the  larynx. 
Succeeding  in  this,  the  child  has  gone  on  again  comparatively  well, 
as  in  whooping-cough,  till  the  returning  spasm  and  vomiting. 
But  in  most  cases  the  discomfort  is  aggravated  towards  evening, 
and  he  passes  a  restless  night,  getting  no  sleep  from  the  irritating 
cough.  Under  these  circumstances,  it  is  a  good  plan  to  give  an 
emetic  at  bedtime ;  say  thirty  drops  of  ipecacuanha  wine  in  an  equal 
quantity  of  simple  syrup.  This  will  usually  cause  vomiting,  and  if 
not,  it  may  be  repeated  in  ten  minutes,  or  even  a  larger  dose  given  ; 
but  this  is  sufficient  in  most  cases,  and  the  child  is  not  depressed  by 
it.  A  saline  and  diaphoretic  mixture,  with  two  or  three  minims  of 
ipecacuanha  wine,  and  the  same  quantity  of  the  compound  tincture 
of  camphor,  will  relieve  the  cough  and  calm  the  nervous  system. 

"When  the  more  acute  symptoms  have  subsided,  a  grain  or  two 
of  bromide  of  potassium  may  be  added  to  each  dose  of  the  mixture 
with  advantage.  Where  the  cough  is  very  irksome,  a  teaspoonful, 
of  a  mixture  composed  of  equal  parts  of  aromatic  syrup  of  senna, 
syrup  of  poppies,  and  syrup  of  squills,  is  worth  giving  occasionally. 
I  sometimes  substitute  the  syrup  of  buckthorn  for  the  senna. 
This  generally  opens  the  bowels,  and  saves  the  necessity  for  more 
active  medicine.  Debility,  pallor  of  foce,  and  a  wasted  and  wan 
look  overtake  the  child  when  shut  up  in  one  room  long  together; 
and  this  is  soon  accompanied  by  a  thick  white  fur  on  the  back  of 
the  tongue,  darkness  under  the  eyes,  and  tremulous  pulse.  A  grain 
of  the  carbonate  of  ammonia  should  be  given  at  this  stage,  with  a 
few  drops  of  syrup  of  Tolu,  under  the  influence  of  which  the  tongue 
cleans  and  the  child  resumes  his  liveliness  ;  to  this  should  be  added 
a  few  drops  of  the  tincture  of  cinchona.  The  child  may  now  be 
brought  downstairs  into  a  large  room,  and  gradually  prepared  to 
be  taken  out  of  doors.  Throughout  an  illness  of  this  kind  it  is 
most  important  to  support  the  bodilj^  strength  with  beef  tea,  veal 
or  chicken  broth,  milk,  thin  arrowroot  and  water,  to  which  a 
third  part  of  milk  is  added,  or  a  little  isinglass  in  milk  and  water. 

21 


'322  DISEASES   OF   CHILDREN. 

CHAPTER   XXTX. 

CROUP  (lartngo-tracheal  diphtheria  of  some  writers). 

Pathology:  Nature  of  the  exudation — Tico  varieties  of  croup — 1.  The  mucous  or  catar- 
rhal— 2.  The  fibrinous  or  inflammatory — Symptoms,  course,  and  progress  of  each  form 
— Morbid  appearances — Clinical  characters  of  true  or  typical  croup — Diagnosis  from 
diphtheria  and  laryngismus — Treatment  by  the  vapor-bath  and  emetics — Antimony — 
Mercury — Aconite — Tracheotomy. 

Among  the  diseases  of  young  children  croup  occupies  a  foremost 
position  from  the  occasional  suddenness  of  its  accession,  the  rapidity 
of  its  course,  and  the  danger  attending  its  termination.  Parents 
readily  recognize  the  first  symptoms  and  are  at  once  alarmed,  and 
the  child  itself  soon  becomes  terrified  to  a  degree  rarely  seen  in 
any  other  disease. 

True  croup  consists  in  an  inflammatory  condition  of  the  mucous 
membrane  of  the  larynx  and  trachea,  with  the  exudation  of  plastic 
lymph,  -vrhich  is  quickly  transformed  into  a  firm  adhesive  mem- 
brane. 

The  inflammation  has  a  tendency  to  seriously  impede  the  func- 
tions of  respiration  by  extending  down  the  air-passages  and  pro- 
ducing troublesome  and  dangerous  inflammatory  complications 
in  the  lungs.  The  disease  is  generally  acknowledged  to  be  more 
frequent  among  male  than  female  children.  In  my  own  experience 
three-fourths  of  all  the  cases  that  have  come  under  my  notice  have 
happened  to  males. 

The  varieties  of  croup  enumerated  by  difierent  authors  are  not 
clearly  to  be  recognized  in  practice.  AYe  may  fairly  speak  of  two 
varieties:  1.  The  mucous  or  catarrhal.  2.  T\\e, fibrinous  or  wflam- 
matory  (croupous  membrane),  according  to  the  predominance  of 
certain  symptoms.  The  disease  is  modified  by  the  age  and  con- 
stitution of  the  child,  and  spasm  or  inflammation  may  be  more 
severe  in  one  case  than  in  another. 

1.  The  catarrhal  or  mucous  form  is  attended  with  hyperemia  of 
the  mucous  membrane,  followed  by  excess  of  secretion  and  dyspnoea. 
The  sj'mptoms  may  be  slow  and  insidious  in  some  cases,  and  the 
catarrh  and  cough,  which  precede  the  stage  of  development,  excite 
no  alarm  till  the  hoarse  voice  and  ringing  cough  announce  the  true 
character  of  the  aftcction.  In  some  instances  we  learn  that  the 
child  has  always  had  a  delicate  chest,  that  any  exposure  to  damp 


CROur.  323 

weather  brings  on  cold  and  congh,  or  it  may  he  traceable  to  bron- 
chitis. The  temperature  in  these  cases  rarely  exceeds  101°.  8uch 
a  history  is  favorable  to  an  attack  of  croup  in  a  yonng  child.  In 
another  case  the  symptoms  are  more  sudden  in  their  accession. 
Delicate  young  children  are  sometimes  seized  whilst  playing.  In 
one  case  that  came  under  my  observation,  a  boy,  ?et.  8,  left  his 
play  at  4  p.m.,  complaining  of  an  uncomfortable  feeling  in  his 
throat,  and  before  six  hours  had  elapsed  the  symptoms  were  severe 
and  dangerous.  In  another  case,  a  strong  and  healthy  child,  pet. 
2|,  was  seized  with  croupal  symptoms  at  11  a.m.,  and  in  eight 
hours  afterwards  they  had  attained  alarming  severity.  Her  parents 
assured  me  that  she  had  slept  well,  and  was  very  brisk  and  lively 
till  the  attack  came  on.  In  these  cases  laryngitis  would  seem  to 
begin  at  once.  Still  it  will  be  found,  with  few  exceptions,  that 
some  catarrhal  and  feverish  symptoms  had  been  present  a  day  or 
two  previous  to  the  attack  of  croup.  If  an  active  emetic  be  given 
at  this  stage  the  breathing  may  rapidly  improve,  though  the  symp- 
toms may  recur  and  require  similar  treatment  in  the  course  of  a 
few  hours.  In  the  majority  of  cases  the  following  day  will  see 
the  child  in  a  fair  way  of  recovery. 

2.  Fibrinous  croup  [tracheo-h iryii gitis — croupous  or  membranous) 
is  the  typical  variet}^  of  the  affection  in  its  severest  form.  This 
is  a  more  acute  or  intense  inflammation;  it  is  a  true  tracheitis, 
with  exudation  of  plastic  material,  because  the  inflammation  affects 
not  only  the  mucous  membrane  but  the  fibrous  tissue  beneath.  I 
will  describe  the  course  of  the  disease  according  to  my  own  per- 
sonal observation.  It  generally  begins  with  hoarseness  of  voice 
and  a  peculiar  harsh  and  ringing  cough,  because  there  is  absolutely 
no  secretion ;  for  the  same  reason  there  is  a  sense  of  constriction 
in  the  trachea.  The  respiration  is  hurried,  and  the  inspiratory 
effort  is  long  and  crowing.  In  some  cases  a  few  hours  will  bring 
about  the  most  severe  symptoms;  the  pomum  Adami  may  be  seen 
rising  and  falling  very  conspicuously  with  respiration  ;  the  eyes 
become  swollen  and  bloodshot,  the  lips  dusky,  and  the  alse  nasi 
active;  the  skin  is  hot  and  dry,  and  the  pulse  small,  hard,  and 
rapid.  Unlike  the  variety  which  has  just  been  described,  the 
temperature  may  reach  103°  or  more.  The  child  may  put  his 
hand  to  his  throat,  and,  in  a  deep  hoarse  voice,  say  or  express  that 
he  cannot  fetch  his  breath.  At  this  stage  the  percussion-note  is 
clear  over  the  thorax,  the  respiratory  murmur  is  much  diminished 


324  DISEASES    OF    CHILDREN. 

througlioLit  the  chest,  and  a  loud  sonorous  rale  attends  it.  ^o 
moist  sounds  have  as  yet  been  heard.  As  the  case  goes  on,  the 
croupal  exudation  becomes  more  organized  and  clings  to  the  larynx, 
when,  if  the  case  progresses  favorably,  either  the  cast  is  thrown 
off  or  resolution  ensues  with  absorption.  If  the  disease  is  extending, 
inspiration  is  now  greatly  impeded  from  blocking  of  the  trachea 
by  the  false  membrane  ;  there  may  also  be  a  tough  piece  of  lymph 
in  the  trachea  which  cannot  be  dislodged.  The  larynx  and  mus- 
cles of  the  neck  are  very  active.  Notwithstanding  the  laborious 
and  painful  respiration  the  child  may,  nevertheless,  sleep  soundly, 
though  waking  occasionally  in  terror.  Thirst  is  generally  present, 
and  swallowing  may  be  painful,  but  I  have  known  a  child  drink  a 
large  cup  of  milk  half  an  hour  before  death.  Still,  any  attempt 
at  deglutition  is  generally  painful  and  brings  on  the  cough.  The 
pulse  now  becomes  small  and  weak,  and  reaches  160 ;  the  crowing 
and  hissing  sounds  in  respiration  increase,  and  the  cough  is  inces- 
sant and  painful.  When  the  symptoms  have  attained  this  inten- 
sity, recovery  is  rare;  the  voice  falls  to  a  whisper, or  departs  alto- 
gether, and  the  cough  is  weak  and  suffocating.  Sometimes,  even 
at  this  stage  of  strangulation,  shreds  of  lymph  and  false  membrane 
are  expelled  by  a  violent  effort  and  paroxj-sm  of  coughing ;  but 
the  relief  is  only  temporary,  and  the  agony  of  oppressed  breathing 
soon  returns.  The  countenance  now  betrays  the  most  painful 
anxiety ;  it  is  bloated  and  distressed,  the  tongue  and  lips  are 
dusky,  and  the  forehead  and  surface  of  the  body  are  bathed  in 
sweat.  The  pulse  becomes  feeble  and  threadlike,  occasionally 
intermitting,  or  falling  in  frequency.  The  child  is  restless,  and 
constantly  turning  about  for  relief,  throwing  the  head  back  against 
the  spine,  or  from  side  to  side,  while  the  j&ngers  are  bent  in  the 
palms  of  the  hand.  Agoijiy  is  depicted  in  every  feature.  The 
struggle  for  breath  goes  on  till  the  little  sufferer  dies  convulsed, 
or  passes  into  a  state  of  stupor  from  which  it  never  wakes  again. 
A  case  that  came  under  my  notice  illustrates  the  sudden  fatal 
termination  not  infrequent  in  this  disease.  The  child,  tet.  3,  had 
been  going  on  well  for  two  days,  and  was  sitting  up  in  bed  play- 
ing with  her  toys,  and  breathing  tranquilly.  In  the  night  the 
respiration  became  embarrassed,  and  she  died  asphyxiated  twelve 
hours  from  the  period  of  relapse.  After  death  a  thin  piece  of 
partially  detached  croupal  exudation  was  found  lodged  in  the 


CROUP.  325 

glottis,  and  this  caused  the  fatal  symptoms  by  occluding  the 
larynx. 

The  false  membrane  found  lining  the  air-passages  varies  in  ex. 
tent;  in  one  of  my  cases  I  found,  on  opening  the  larynx  and 
trachea,  three  long  and  narrow  pieces  of  lymph,  one  upwards  of 
two  inches  in  length,  and  the  others  nearly  as  long,  between  the 
lower  border  of  the  cricoid  cartilage  and  the  last  rings  of  the 
trachea,  without  any  extension  to  the  bronchi.  In  this  case  moist 
sounds  were  heard  in  the  chest  on  the  second  day  of  the  illness  ; 
but  they  had  disappeared  on  the  fourth  and  fatal  day,  ]^ear  the 
level  of  the  upper  border  of  the  cricoid  cartilage  were  to  be  seen 
small  tough  fragments  of  lymph,  not  readily  detached  from  the 
surface  beneath.  The  mucous  membrane  was  everywhere  red,  and 
in  places  vividly  so ;  but  there  was  not  any  evidence  of  sub- 
mucous effusion,  for  it  must  be  remembered  that  the  connective 
tissue  of  the  larynx  is  very  small  in  quantity.  In  other  cases, 
lymph  may  be  observed  throughout  the  trachea,  and  the  mucous 
membrane  may  be  pale,  except  in  isolated  patches,  where  it  is  red 
and  vascular.  The  false  membrane  varies  much  in  form  and  con- 
sistency ;  sometimes  it  is  cylindrical  in  shape,  and  loose,  or  ad- 
herent to  the  mucous  membrane  beneath,  from  which  it  is  not 
readily  separated  ;  in  other  instances  it  is  moulded  to  the  shape 
of  the  bronchial  tubes,  where  the  inflammation  has  extended  into 
the  lungs,  and  in  these  cases  the  efforts  of  vomiting  fail  to  bring 
away  the  source  of  irritation,  and  the  danger  to  life  is  thereby 
increased.  When  the  false  membrane  is  loose  and  fragile,  it  is 
easier  of  expectoration  ;  and  it  is  these  cases  that  have  the  best 
chance  of  recovery,  particularly  if  limited  to  the  larynx  and  trachea, 
the  lungs  not  being  involved  in  the  inflammatory  process. 

Of  late  so  much  difference  of  opinion  has  arisen  on  the  pathology 
of  croup  that  we  are  induced  to  ask  what  is  understood  by  the 
term?*  Until  recently  it  has  generally  been  regarded  as  a  local 
disease,  an  inflammation  of  the  trachea  attended  with  the  forma- 
tion of  false  membrane  (croupal  exudation),  though  the  practical 
physician  most  commonly  recognizes  the  disease  by  the  spasmodic 
closure  of  the  glottis,  the  prolonged  and  crowing  inspiration,  and 

*  The  result  of  the  discussion  on  membranous  croup  and  diphtheria  at  the  Royal 
Medical  and  Chirurgical  Society  in  1879  was,  that  membranous  laryngitis  may  arise 
from  common  inflammation,  or  in  connection  with  specific  disorders  of  various  kinds, 
but  that  the  most  frequent  cause  is  diphtheria. 


326  DISEASES    OF    CHILDREN. 

the  fear  of  impending  suffocation.  If  to  these  symptoms  are 
added  fever  and  inflammatory  excitement,  he  has  no  doubt  what- 
ever that  he  is  dealing  with  a  case  of  genuine  typical  croup,  such 
as  had  been  known  before  diphtheria  was  recognized  and  dis- 
tinguished in  this  country.  To  me  it  appears  that  croup,  whether 
simple  or  membranous,  is  a  totally  different  disease  from  diph- 
theria, and  that  they  only  approach  an}''  degree  of  relationship 
when  the  latter  disease  has  invaded  the  larynx,  and  then  the 
symptoms  due  to  obstructed  breathing  are  much  the  same  in  both 
cases. 

We  constantly  meet  with  genuine  croup  of  an  acute  and  local 
inflammatory  character,  leading  to  the  well-known  false  mem- 
brane in  the  trachea  and  larynx,  as  described  by  the  old-fashioned 
authorities.  It  seems  impossible  that  we  can  mistake  this  true 
croup  (which  we  have  been  in  the  habit  of  meeting  with  all  our 
lives)  for  the  peculiar  membranous  inflammation  of  the  trachea 
sometimes  seen  in  cases  of  diphtheria.  It  is  well  to  glance  at 
some  remarkable  points  of  dift'erence  in  the  two  affections. 

1.  True  croup  is  prone  to  attack  the  healthiest  children,  and  in 
districts  where  diphtheria  does  not  prevail.* 

2.  True  croup  is  apt  to  come  on  very  suddenly,  and  in  cases  of 
recovery  the  general  health  is  rapidly  re-established,  as  compared 
with  diphtheria. 

3.  In  diphtheritic  croup  the  disease  is  of  a  well-marked  consti- 

*  There  are  many  instances  on  record  of  a  whole  family  of  children  dying  of  diph- 
theria in  the  course  of  twenty  or  thirty  days-  Malignant  epidemics  of  this  nature 
have  prevailed  in  this  country  since  1857 ;  but  we  have  never  known  of  three  cases  of 
genuine  croup  happening  at  one  and  the  same  time  to  a  single  family,  and  we  have 
never  known  them  last  so  long.  The  recurrence  of  diphtheria  in  the  same  house  has 
been  noticed  over  and  over  again,  and  traced  to  bad  drainage,  proving  that  the  power 
of  contagion  lurks  and  lingers  about,  ready  to  seize  on  any  person  lowered  in  liealth  or 
8uscei)tiljle  to  its  influence.  The  disease  is  most  prone  to  attack  delicate  children, 
whose  iionies  are  badly  ventilated,  and  where  sanitary  precautions  are  neglected. 

It  would  be  impossil)le  for  the  want  of  space  to  enter  here  into  the  long  and  vexed 
question  as  to  whether  the  croup  of  Home  and  Chsyne  in  tliis  country  is  the  same  dis- 
ease as  the  "diphtiierite"  of  Bretonneau.  I  can  discover  nothing  to  warrant  this 
conclusion,  for,  if  identical,  surely  modern  writers  would  have  had  their  attention  di- 
rected to  the  resemblance  in  the  course  of  long  and  varied  experience.  Diphtheria  is 
a  disease  only  recently  described  with  precision;  as  soon  as  attention  was  directed  to 
it  pliysicians  at  once  recognized  a  new  disorder,  both  in  its  anatomical  and  clinical 
features,  entirely  dilPerent  from  anyiliing  tliey  had  previously  seen,  and  presenting 
symptoms  at  complete  variance  with  the  so-called  inflammatory  or  true  croup. 


CROUP.  327 

tutional  character,  and  is  always  accompanied  by  great  depression 
and  nervous  symptoms. 

4.  Croup  is  a  local  disease ;  diphtheria  is  a  constitutional  affec- 
tion, in  which  the  kidneys  and  intestines  may  be  involved.  Croup 
is  neither  infectious  nor  contagious  ;  diphtheria  is  both. 

5.  The  cases  that  recover  from  diphtheritic  croup  are  few,  and 
the  convalescence  is  not  only  very  slow  and  tedious,  but  the  throat 
affection  is  usually  preceded  by  a  characteristic  membrane  on  the 
palate,  and  the  prostration  is  always  great.  Partial  loss  of  voice, 
fetid  breath,  swollen  neck  and  glands,  diminution  of  muscular 
power,  paralj'Sis  of  the  muscles  of  deglutition,  and  albuminuria 
are  common  in  diphtheria  ;  but  they  are  not  witnessed  in  inflam- 
matory croup. 

6.  Between  croup  and  diphtheria  there  is  also  another  very  im- 
portant diagnostic  difference ;  diphtheria  generally  begins  in  the 
pharynx,  croup  in  the  larynx.*  The  false  membrane  found  in  the 
larynx  in  cases  of  genuine  croup  is  quite  different  from  the  leathery 
or  yellowish-gray  exudation  found  on  the  tonsils,  in  the  larynx,  and 
bronchial  tubes  in  cases  of  diphtheria.  The  pathological  differ- 
ences between  croup  and  diphtheria  are  open  to  further  contrast. 
In  the  early  stage  of  croup  there  is  an  increase  in  the  vascularity 
of  the  affected  membrane,  as  in  severe  catarrh,  with  a  trifling 
amount  of  inflammatory  exudation.  This  is  succeeded  by  fibril- 
lation of  the  exuded  lymph,  which,  with  the  new-formed  cellular 
elements,  becomes  transformed  into  the  characteristic  false  mem- 
hrane.  Its  consistence  varies,  being  in  some  cases  tough,  in  others 
soft  and  amorphous,  and  easily  removed  from  the  mucous  mem- 
brane beneath.  In  the  larynx  and  upper  part  of  the  trachea, 
where  the  inflammation  is  most  acute,  the  exudation  is  croupal  or 
membranous,  and  is  very  characteristic  of  true  croup,  but  in  the 
lowest  part  of  the  trachea  and  diverging  bronchi,  there  may  be 
nothing  more  than  a  scanty  superficial  layer  of  mucus. 

-X-  "  ]yjy  ifiga,  of  the  problem  to  be  solved  is,  in  fact,  this :  It  must  be  admitted  that 
the  diphtheritic  poison  is  capable  of  giving  rise  to  a  plastic  inflammation  of  the  larynx, 
apart  from  the  existence  of  any  similar  afl^ection  of  the  pharynx.  But  there  is  good 
reason  to  believe  that  during  epidemics  of  diphtheria  the  cases  in  whicli  tliis  occurs  are 
in  the  highest  degree  exceptional.  If,  therefore,  it  can  be  shown  that  in  the  practice 
of  a  general  hospital  the  cases  of  plastic  laryngitis,  of  uncertain  origin,  bear  a  large 
proportion  to  the  total  number  of  cases  of  diphtheria,  tliere  will  be  a  strong  probability 
that  the  majority  of  the  former  cases  are  dependent  upon  some  other  cause  than  the 
diphtheritic  poison." — Diphtheria  and  Croup,  by  W.  H.  Lamb,  M.B.,  and  C.  Hilton 
Fagge,  M.D.,  Guy's  Hospital  Eeports,  1877,  p.  345. 


328  DISEASES   OF   CHILDREN. 

"  It  is  difficult  in  mauy  cases  to  draw  any  line  of  demarcation 
between  the  histological  changes  occurring  in  diphtheria  and  those 
of  croup.  In  diphtheria,  however,  the  submucous  tissue  usually 
becomes  more  extensively  involved,  so  that  the  false  membrane  is 
much  less  readily  removed.  The  circulation  also  often  becomes  so 
much  interfered  with  that  portions  of  the  tissue  lose  their  vitality, 
and  large  ash-colored  sloughs  are  formed,  which,  after  removal, 
leave  a  considerable  loss  of  substance."* 

7.  If  croup  Avere  identical  with  diphtheria,  it  seems  to  me  that 
the  operation  of  tracheotomy  would  rarely  succeed  ;  whereas  it  is 
often  successful  when  false  membrane  has  blocked  up  the  tracheal 
tube,  and  has  been  removed  from  time  to  time  after  the  operation. 

The  following  affords  an  excellent  illustration  of  the  comparison 
between  croup  and  diphtheria. 

Dr.  Sansom  has  related  a  case  of  pharyngo-laryngeal  diphtheria 
with  albuminuria,  in  a  female  child  four  and  a  half  years  old, 
where  tracheotomy  was  resorted  to  on  account  of  dyspnoea  and 
embarrassed  breathing.  AVhite  patches  were  observed  on  the 
pharj-nx  and  right  tonsil.  The  edges  of  the  wound  were  covered 
with  diphtheritic  false  membrane, and  sloughing  proceeded, accom- 
panied with  extreme  prostration.  A  wound  of  the  ring  finger  of 
the  right  hand  was  covered  by  false  membrane,  and  from  this 
wound  ulceration  extended,  and  involved  a  part  of  the  right  hand. 
During  the  following  week  there  was  little  change,  then  extreme 
adynamia  ensued,  pneumonia  attacked  the  bases  of  both  lungs, 
and  the  child  died  sixteen  days  after  the  operation  of  tracheotomy. 
After  death  the  larj^nx  was  covered  with  false  membrane,  the 
tissues  around  the  tracheal  wound  were  infiltrated,  and  there  was 
sloughing  of  the  soft  structures.  The  kidneys  were  in  a  state  of 
acute  nephritis,  and  the  lungs  showed  diffused  brouchopneumonia.t 

The  treatment  that  would  put  an  end  to  catarrhal  croup  would 
hourly  aggravate  a  case  of  diphtheria  and  hasten  death.  This 
alone  is  sufficient  to  convince  us  that  the  two  diseases  are  essen- 
tially different.  A  child  is  put  to  bed  in  an  atmosphere  of  steam, 
suffering  from  acute  croup,  and  after  the  action  of  tartar  emetic, 
and  perhaps  a  grain  of  calomel,  the  alarming  symptoms  gradually 
subside.     This  is  never  seen  in  a  case  of  diplitheria ;  the  nervous 


*  Pathology  and  Morbid  Anatomy,  by  T.  H.  Green,  M.D.,  3d  edition,  1875,  p.  303. 
I  Croup  and  Dii)htheria:  a  Contrast,  Med.  Soc.  Proc,  vol.  iii,  1875-77,  p.  105. 


CROUP.  329 

prostration  which  invariably  accompanies  it  would  be  aggravated, 
and  life  probably  sacrificed,  by  the  adoption  of  such  treatment. 

Laryngismus  striduhis  is  another  disease  which  is  apt  to  be  mis- 
taken for  croup;  but  the  following  diagnostic  points  of  difference 
are  so  broad  and  clear  that  in  ordinary  and  well-developed  cases 
it  would  be  inexcusable  to  confuse  them : 

1.  Laryngismus  usually  sets  in  suddenly  with  alarming  sj-mp- 
toms,  and  terminates  abruptly  ;  in  true  croup  the  invasion  is  less 
sudden,  there  has  been  cough  and  febrile  disturbance  for  a  day  or 
two,  and  the  symptoms,  instead  of  declining,  go  on  increasing  in 
severity. 

2.  In  a  typical  case  of  larjaigismus  the  voice  is  unaffected,  and 
there  is  no  cough ;  in  croup  there  is  both  cough  and  change  of 
voice,  and  the  latter  is  often  weak  and  feeble  from  the  commence- 
ment. 

3.  In  larjargismus  there  is  no  expectoration  nor  any  catarrhal 
sounds  in  the  chest ;  in  croup  such  symptoms  are  constantly  met 
with. 

4.  In  laryngismus  there  is  no  fever  (that  is,  sufficient  rise  of 
temperature  to  deserve  the  name  of  fever),  and  the  circulation  is 
undisturbed,  except  during  the  paroxysms ;  in  croup  the  fever  runs 
very  high,  there  is  thirst,  heat  of  skin,  and  quick  pulse. 

5.  Age  comes  greatly  to  our  aid.  Laryngismus  is  most  common 
in  infants  during  dentition  ;  croup  is  most  frequent  between  the 
second  and  fifth  j^ears. 

6.  Larjmgismus  is  most  common  among  strumous  and  rickety 
children,  and  those  who  have  been  ailing  and  out  of  health.  It  is 
constantly  associated  with  dentition,  and  overfeeding  or  improper 
food ;  croup  often  attacks  the  healthiest  and  strongest  children, 
and  generally  arises  from  exposure  to  cold  winds,  or  damp;  it  is 
far  more  frequently  fatal  than  laryngismus,  which  is  only  excep- 
tionally dangerous. 

7.  In  croup  there  is  not  the  same  immediate  violent  struggling 
for  breath  as  in  larjaigismus ;  then,  too,  in  laryngismus  there  is 
complete  recovery  between  the  paroxj'sms. 

8.  In  laryngismus  the  condition  is  one  rather  of  sjnicope  or 
fainting ;  the  attacks  are  usually  too  short  to  produce  permanent 
lividity  from  imperfect  aeration  of  the  blood. 

9.  In  larjmgismus  death  may  occur  from  complete  asphyxia  ;  in 
croup  a  sudden  termination  may  result  from  a  portion  of  detached 


330  DISEASES    OF    CHILDREX. 

false  membrane  exciting  fatal  spasm  of  the  larynx ;  but  death 
usually  happens  from  interrupted  respiration  and  circulation 
through  the  lungs,  with  gradual  depression  of  the  vital  powers. 

10.  In  a  case  of  larj-ngismus  the  inspiratory  effort  is  tempo- 
rarily affected,  arrested,  or  even  stopped  entirely;  whilst  in  croup, 
the  embarrassed  breathing  is  permanent,  and  expiration  as  well  as 
inspiration  are  both  involved. 

11.  The  treatment  of  the  two  affections  is  diametrically  op- 
posed ;  the  remedies  that  would  relieve  the  one  would  aggra- 
vate the  other. 

So  much  for  the  distinctions  of  laryngismus  from  croup.  But  I 
must  not  dismiss  this  question  of  diagnosis  without  admitting 
that  there  are  complicated  or  mixed  cases,  attended  with  wheez- 
ing and  catarrhal  s^miptoms,  where  a  degree  of  catarrhal  inflam- 
mation is  mixed  up  with  the  spasmodic  affection.  These  are  the 
cases  which  more  nearly  resemble  true  croup,  cases  of  modified 
larj'ngismus  happening  to  young  children,  where  we  have  no  such 
precise  landmarks  as  those  I  have  attempted  to  define.  They 
commence  with  slight  catarah  [catarrhal  laryngitis)^  hoarse  and 
noisy  cough  a  day  or  two  before  the  characteristic  crowing  inspi- 
ration, and  they  sometimes  precede  an  attack  of  pneumonia  or 
measles.  It  is  cases  of  this  kind,  attended  with  a  croupy  cough, 
which  are  apt  to  deceive  and  mislead  us ;  there  is,  in  fact,  some 
swelling  and  inflammatory  action  of  the  larynx  and  vocal  cords 
added  to  the  original  spasmodic  affection.  The  presence  of  cough, 
with  wheezing  and  dyspnoea,  might  induce  even  a  practiced 
observer  to  think  he  was  dealing  with  an  ordinary  case  of  croup, 
but  as  it  advances  he  is  able  to  satisfy  himself  that  genuine  spasm 
is  at  the  root  of  the  evil.  In  the  simplest  forms  of  catarrh  in 
some  young  children,  the  voice  is  hoarse  and  the  cough  barking. 
To  such  an  extent  does  this  prevail,  that  a  diagnosis  is  not  in  vari- 
ably' easy  at  the  beginning  of  an  illness.  The  mucous  membrane 
of  the  larynx  is  highly  irritable  and  sensitive,  and  readily  becomes 
inflamed  and  swollen  on  exposure  to  cold  air.  This  is  probably 
the  condition  that  is  present  in  those  cases  of  laryngismus  attended 
with  incessant  and  croupy  cough.  Though  we  must  not  expect 
to  find  the  same  pathological  change,  or  the  same  catalogue  of 
symptoms,  in  all  cases  of  larj-ngismus,  still,  viewing  these  cases 
from  what  point  of  view  we  may,  I  can  seldom  imagine  any  real 
difficulty  to  obscure  the  diagnosis  of  these  two  affections,  if  we 


CEOUP.  331 

bear  in  mind  that  in  genuine  laryngismus  the  larynx  and  trachea 
are  free  from  inflammation,  that  the  attacks  are  sudden  and  tem- 
porary, that  there  is  no  cough  and  no  fever;  all  which  symptoms 
are  the  accompaniments  of  croup. 

Of  the  forms  of  croup,  there  is  :  1.  The  catarrhal  croup,  a  mild 
class  of  cases  of  frequent  occurrence,  which  rarely  places  the  life 
of  the  patient  in  imminent  danger.  It  may  come  on  in  the  night, 
with  some  heat  of  skin,  frequent  husky  cough,  quick  pulse,  and 
flushed  face ;  and  for  a  few  hours  the  symptoms  are  severe  and 
alarming  to  the  parents  ;  even  the  medical  attendant  is  doubtful 
about  the  issue  of  the  case  ;  but  after  a  dose  of  calomel  and  the 
free  action  of  an  emetic  (the  room  being  kept  moist,  and  its  tem- 
perature high),  the  symptoms  soon  decline,  and  the  child  is 
himself  again,  with  the  exception  of  being  a  little  prostrate  and 
pallid. 

2.  The  fibrinous  croiq^  or  tracheitis,  happening  to  healthy  chil- 
dren, wdiich  comes  on  suddenly  and  is  attended  throughout  with 
danger.  These  cases  are  rapid  in  their  onset,  and  are  quickly 
fatal. 

The  tendency  to  a  recurrence  of  croup  in  some  children  is  a 
favorable  sign  so  far  as  regards  its  severity  ;  such  cases  seldom 
terminate  fatally,  for  these  are  of  the  catarrhal  form.  If  we  are 
told  that  the  child  has  had  one  or  two  previous  attacks,  we  may 
generally  regard  the  case  as  satisfactory.  Such  cases  stop  short 
of  actual  exudation,  and  spasm  also  plays  an  important  part  in 
the  production  of  the  symptoms.  The  mucous  membrane  of  the 
larynx  and  trachea  is  in  a  state  of  inflammatory  excitement,  and 
the  vessels  are  full  and  congested.  Prompt  treatment  rapidly 
unloads  the  distended  vessels  and  encourages  expectoration.  In- 
telligent mothers,  whose  children  are  so  attacked,  come  at  last  to 
view  the  symptoms  with  little  or  no  anxiety,  feeling  confident 
that  a  good  flre,  with  a  steaming  kettle  in  the  room,  a  brisk 
emetic,  and  hot  sponges  kept  constantly  applied  to  the  throat, 
will  soon  bring  the  child  round.  The  lesson  to  be  learnt  here,  as 
in  every  other  variety  of  croup,  is  to  lose  no  time,  for  success  in 
treatment  depends  on  meeting  the  symptoms  w^th  promptitude. 
Above  all,  care  must  be  taken  not  to  confound  these  cases  w'ith 
laryngismus,  for  in  the  one  there  is  fever  and  persistent  difiicult 
breathing,  whilst  in  the  other  there  is  no  fever,  and  the  breathing 
between  the  paroxysms  is  calm  and  tranquil. 


332  DISEASES   OF   CHILDEEN. 

Treatment. — Careful  study  of  the  disease  lias  done  much  to 
instruct  the  medical  attendant,  and  the  knowledge  that  no  time 
is  to  be  lost  is  so  commonly  spread,  that  before  we  are  summoned 
to  give  relief  some  useful  measures  have  been  tried,  and  thus 
many  lives  are  saved  which  neglect  would  have  rendered  hope- 
less ;  3'et  for  all  this  it  is  estimated,  according  to  the  returns  of 
the  Eegistrar-General,  that  about  6000  children  die  annually  of 
croup  in  the  United  Kingdom,  a  mortality  which  ought  to  en- 
lighten us  as  to  its  fatal  nature,  and  induce  us  to  study  the  best 
method  of  dealing  with  it. 

I  have  observed  nothing  of  late  j^ears  to  induce  me  materially 
to  alter  my  opinion  from  the  following  conclusions,  at  which  I 
arrived  in  1863  :* 

1.  The  temperature  of  the  room  should  not  be  lower  than  65°. 

2.  The  vapor-bath  is  indispensable  in  the  treatment  of  croup, 
and  should  be  used  at  the  commencement  in  every  case,  and  con- 
tinued unremittingly  until  all  fear  of  a  relapse  has  departed. 

3.  All  cases  of  croup  are  invariably  relieved  by  the  vapor-bath, 
especially  if  the  tracheal  membrane  is  dry  ;  when  it  is  moist  there 
might  be  fear  of  causing  too  much  depression. 

4.  The  earlier  that  a  case  comes  under  treatment  the  greater  the 
probability  of  a  successful  termination,  because  it  is  then  possible 
to  prevent  the  tracheal  secretion  becoming  organized. 

5.  The  most  trying  difficulty  we  have  to  contend  wdth  in  the 
management  of  croup  in  the  catarrhal  form  is  a  relapse,  because 
with  it  comes  exhaustion  ;  and  the  weaker  the  patient  the  less  will 
be  the  chance  of  recoverj-. 

6.  Tartarated  antimony  is  our  sheet-anchor  as  a  medicinal  agent, 
not  so  much  from  any  specific  effect  it  exerts  on  the  tracheal  mem- 
brane as  from  its  certainty  in  effecting  free  and  speedy  vomiting. 

7.  When  the  emetic  has  fully  operated,  if  there  be  much  febrile 
excitement  and  disordered  primse  vi^e,  which  aggravate  the  laryn- 
geal symptoms,  a  grain  of  calomel  every  four  hours,  or  one  full 
dose  for  the  purpose  of  emptying  the  bowels  and  controlling  the 
fever  will  be  found  necessar3^  In  the  fibrinous  form,  when  there 
is  violent  and  acute  inflammation,  with  a  firm  hard  pulse,  and  a 
full  reserve  of  strength,  two  or  three  leeches  may  be  applied  over 
the  thyroid  cartilage,  and  bleeding  can  easily  be  arrested  by  pres- 
sure with  the  finger,  and  if  need  be  with  cotton-wool ;  then  mer- 

*  Brit.  Med.  Journ.,  May  30th. 


CEOUP.  333 

carj  may  prove  a  valuable  addition  to  the  antimonial  treatment. 
Some  of  my  cases  improved  from  the  moment  the  mercury  aftected. 
the  bowels,  the  fever  diminishing,  and  the  expectoration  of  the 
false  membrane  being  promoted.  When  employed  in  small  doses 
at  regular  intervals,  it  would  appear  to  diminish  the  cohesive  at- 
tachment to  the  mucous  membrane,  and  to  render  the  lymph  less 
fibrinous  and  more  readily  absorbed. 

8.  AYhen  in  a  case  of  croup,  seen  at  an  early  stage,  and  satisfac- 
torily progressing,  forty-eight  hours  have  elapsed,  we  may  gener- 
ally augur  a  favorable  termination  ;  and  we  should  then  begin,  if 
not  before,  to  support  our  patients  with  good  beef  tea,  milk,  and 
arrowroot,  and  (it  may  be)  a  little  wine  and  water. 

If  after  vomiting  the  temperature  remains  high,  and  especially 
when  the  bowels  have  acted  freely,  minim  doses  of  aconite  every 
two  or  three  hours  are  of  great  service  in  inflammatory  croup. 
This  keeps  up  a  gentle  diaphoretic  action  on  the  skin,  diminishes 
tension  of  the  pulse,  and  controls  vascular  excitement  in  a  very 
striking  manner.  At  this  stage  it  comes  in  well,  because  antimony 
should  not  be  long  continued  in  any  of  the  diseases  of  children, 
and  it  certainly  ought  not  to  be  in  this  disorder. 

On  the  question  of  tracheotomy,  I  am  inclined  to  think  we  may 
urge  a  great  deal  in  its  favor.*  ^yhen  the  respiration  is  so  in- 
volved as  to  produce  almost  complete  unconsciousness,  swelling 
and  distension  of  the  features,  and  lividity  of  the  lips  (convulsive 
efforts  that  indicate  approaching  suffocation),  we  should  cling  to 
the  chance  it  holds  out.  When  all  remedies  have  failed  to  improve 
the  patient's  condition,  and  death  is  near  at  hand,  we  should  not 
let  the  patient  die  without  giving  him  the  chance  of  life  which  an 
operation  affords. 

In  most  of  the  cases  of  tracheotomy  that  have  fallen  under  my 
notice  I  have  almost  invariably  observed  an  improvement  for  a 
time  in  the  respiration,  and  the  fact  that  a  few  days  have  been 
gained  when  death  must  have  terminated  in  as  many  hours  is  a 
great  point  in  favor  of  the  operation,  and  for  not  delaying  it  too 
long.  If  tracheotomy  is  to  succeed,  it  must  be  done  before  the 
strength  is  quite  exhausted  and  asphyxia  has  thoroughly  set  in. 
M.  E.  Dudon,  of  the  Hopital  St.  Andre,  Bordeaux,  performed  the 
operation  in  twelve  cases,  with  six  recoveries  ;  and  he  is  of  opinion 
that  could  he  have  performed  the  operation  earlier  in  some  of  the 

*  See  the  remarks  on  tracheotomy  in  the  next  chapter. 


334  DISEASES   OP   CHILDREN. 

otlier  cases  lie  would  have  had  more  recoveries.  When  medical 
means  have  failed,  and  the  larynx  is  invaded  by  false  membranes, 
which  cannot  be  got  rid  of  by  vomiting  or  other  means,  M.  Dudou 
thinks  tracheotomy  justifiable.* 

It  should  be  onr  earnest  endeavor  to  recognize  whether  we  are 
dealing  with  the  catarrhal  or  the  fibrinous  form  of  croup.  If  we 
are  convinced  it  is  the  fibrinous  form,  then  it  must  be  at  the  dis- 
cretion of  the  surgeon  whether  or  not  the  symptoms  are  such  as 
to  lead  him  to  expect  that  resolution  will  take  place.  If  not, 
tracheotomy  should  be  performed  at  once,  as  its  postponement 
would  render  a  successful  issue  less  probable. 

Tracheotomy  in  itself  is  not  a  dangerous  operation,  but  if  it  be 
delayed  till  the  lining  membrane  of  the  larynx  and  trachea  are 
covered  with  false  membrane,  extending  as  far  as  the  primary 
divisions  of  the  bronchi,  and  the  constitutional  symptoms  are  be- 
coming severe,  the  chances  of  its  success  are  materially  diminished. 
This  we  often  see  when  tracheotomy  has  been  performed  at  too 
late  a  period  of  the  disease,  and  the  operation  has  the  discredit  of 
the  fatal  result. 

When  extensive,  or  loose,  or  purulent  portions  of  false  mem- 
brane occupy  the  primary  branches  of  the  bronchi,  and  extend  to 
and  choke  up  the  smaller  or  minute  bronchi,  the  operation  cannot 
be  expected  to  succeed.  It  is  frequently  performed  as  a  last  re- 
source, when  the  respiration  is  impeded  and  embarrassed,  and  ex- 
haustion has  advanced  too  far.  Under  a  combination  of  asphyxia 
and  asthenia  the  child  sinks. 

In  those  children  who  survive  the  operation  for  some  days, 
bronchitis,  pneumonia,  bronchopneumonia,  and  convulsions  are 
the  most  frequent  causes  of  death.  A  tendency  to  pulmonary  ex- 
citement already  exists,  and  indeed  the  operation  itself  is  calcu- 
lated to  originate  it.  Tracheotomy  is  a  very  successful  operation 
when  performed  for  the  relief  of  chronic  laryngeal  diseases,  or  for 
the  removal  of  foreign  bodies  from  the  air-passages.  But  it  is 
significant  that  this  operation  does  not  generally  yield  satisfactory 
results  when  undertaken  in  cases  of  oedema  of  the  glottis,  occur- 
ring in  children  who  have  sucked  boiling  water  from  the  spouts 
of  kettles.  After  this  grave  accident,  lung  affections  very  often 
supervene,  from  the  inspiration  of  scalding  vapor  simultaneously 
with  the  boiling  fluid.     Tracheotomy  aggravates  the  pulmonary 

*  The  Lancet,  July  20th,  1872. 


CROUP.  335 

complication ;  yet  it  must  be  done,  on  account  of  the  oedema  of 
the  glottis.  Yeiy  similar  considerations  apply  to  croup.  In  some 
cases  where  children  have  been  saved  from  the  prospect  of  imme- 
diate death  by  tracheotomy,  and  the  canula  cannot  be  removed 
•with  safety  for  a  moment  without  the  danger  of  asphyxia,  the 
chances  of  ultimate  recovery  are  ver}^  slight.  The  little  patient, 
having  rallied  from  the  operation,  goes  on  satisfactorily  for  some 
days,  when  it  becomes  restless  and  feverish  at  night,  with  a  hot 
skin  and  a  quick  pulse.  If  we  auscultate  the  chest,  we  find  exten- 
sive bronchitis,  and  perhaps  some  pneumonia.  No  more  sputa 
are  evacuated  through  the  canula,  and  the  child  soon  becomes  con- 
vulsed, or  dies  in  a  comatose  condition.  There  may  be  no  accu- 
mulation of  false  membrane  in  the  larynx ;  but  if  the  glottis  is 
nearly  closed  by  swelling  and  oedema,  and  the  mucous  membrane 
injected  and  vascular,  the  extension  of  inflammation  down  the 
trachea  and  bronchi  into  the  tissue  of  the  lung  is  almost  certain 
to  ensue.  If  the  case  goes  on,  abscess  of  a  portion  of  the  lung, 
pleurisy,  or  empyema  are  among  the  morbid  changes  discovered 
after  death.  From  all  I  have  been  able  to  ascertain,  the  operation 
of  tracheotomy  is  less  likely  to  succeed  in  children  under  two  3^ ears 
of  age  than  in  those  above  it.  The  trachea  is  small  and  unde- 
veloped, it  is  not  so  easily  reached  as  in  older  children,  and  haemor- 
rhage may  occur,  but  a  competent  surgeon  may  readily  overcome 
it.  Yet  in  the  face  of  these  diificulties  infants  have  survived  the 
operation ;  but  the  greatest  number  of  recoveries  has  occurred  be- 
tween the  ages  of  five  and  six  years. 

It  has  been  alleged  that  the  direct  admission  of  air  to  the  luno's 
without  having  previously  passed  through  the  mouth  and  nasal 
passages,  is  attended  with  real  danger,  and  that  congestion  of  the 
lungs  is  another  danger  induced  by  the  operation.  But  seeino- 
that  the  temperature  of  the  room  can  be  raised  to  any  extent,  and 
that  appliances  for  the  supply  of  warm  moist  air  are  to  be  pro- 
cured, congestion  of  the  lungs  from  this  cause  alone  ought  not  to 
occur. 


336  DISEASES    OF    CHILDREN. 

CHAPTER  XXX. 

DIPHTHERIA. 

Stiiptoms:  Period  of  incubation — Insidious  approach  of  the  disease  before  any  complaint 
of  illness  is  made — Elevation  of  temperature —  Weakness  of  the  pulse  an  early  and  sig- 
nificant feature  of  the  disease — Albumen  in  the  urine — Character  of  the  throat  affection 
and  peculiarities  of  the  exudation — Constitutional  depression  and  implication  of  the 
larynx  and  voice — Diphtheritic  croup — Tendency  to  delirium  and  restlessness — Death 
by  suffocation  or  asthenia.  Causes:  Influence  of  a  specific  cause — Debility  and 
exhaustion  predispose  to  the  affection — Effects  of  locality  and  moisture  in  favoring  its 
occurrence.  SEQUELiE:  Anaemia,  debility,  and  paresis — Weak  action  of  the  heart, 
secondary  endocarditis — Paralysis  of  the  tUuscles  of  deglutition  and  upper  and  lovjer 
extremities — Impaired  vision  and  deafness — Bronchitis  and  pneumonia — Albuminuria 
— Hcemorrhage  from  nose  and  bronchi.  Morbid  Anatomy  :  Bronchitis  and  pneu- 
monia— Fibrinous  coagula  in  the  heart — Congestion  of  kidneys,  brain,  and  spinal 
cord.  Diagnosis  of  the  affection  from  croup,  scarlet  fever,  and  tonsillitis — Theory  of 
contagion.  Treatment  :  Local  and  constitutional — Necessity  of  supporting  the  gen- 
eral strength  by  nourishment  and  stimulants —  Value  of  iron  and  other  tonic  prepara- 
tions— Applications  to  the  throat  as  in  .scarlet  fever — Importance  of  tracheotomy  in 
imminent  death  from  suffocation — Statistics  of  Professor  George  Buchanan,  of  Glasgow, 
in  croup  and  diphtheria — Strychnia  and  galvanism  in  diphtherial  paralysis. 

Diphtheria  (diplitherite  of  Bretonneau)  is  a  contagious  and 
epidemic  disorder,  characterized  by  a  specific  inflammation  of  the 
pharynx  and  air-passages,  attended  with  the  exudation  of  fibrin  or 
other  lymph,  and  the  enlargement  of  the  cervical  glands.  Other 
mucous  membranes  or  the  skin  may  be  sometimes  involved.  The 
vital  powers  are  greatly  prostrated.  Death  takes  place  from  ex- 
haustion or  suffocation  through  diphtheritic  deposit  in  the  trachea 
and  larynx.  Diphtheria  bears  an  aflinity  to  the  exanthemata  in 
the  fact  that  it  chiefly  attacks  the  young.  The  mortality  is 
greatest  between  the  ages  of  five  and  ten  years,  but  infants  of  a 
few  days  old  have  been  attacked. 

Evidence  of  the  antiquity  of  the  disease  is  to  be  found  in  the 
writings  of  Hippocrates,  Celsus,  Aretseus,  Galen,  and  Ccelius  Aure- 
lianus.  In  more  modern  times,  descriptions  of  it  are  given  by 
Spanish,  Italian,  French,  and  English  writers,  and  traces  of  its 
progress  have  been  met  with  in  America,  Africa,  aud  Hindostan. 
It  prevailed  in  Holland  in  the  sixteenth  century.  By  some  writers 
it  is  thought  to  be  the  same  disease  that  was  known  a  hundred 
years  ago  under  the  name  of  epidemic  croup  and  malignant  sore 
throat.*     It  made  its  appearance  at  Tours,  in  France,  in  1818. 


*  Dr.  Fothergill's  account  of  the  sore  throat  attended  with  ulcers,  1748. 


DIPHTHEEIA.  337 

This  disease,  until  the  last  few  years,  has  been  confouiidecl  with 
erysipelas  and  scarlet  fever  during  their  epidemic  prevalence.  The 
credit  belongs  to  Bretonneau  of  being  the  first  writer  to  define  its 
exact  nature,  and  to  show  that  the  local  appearances  on  the  throat 
and  fauces  are  the  manifestations  of  a  general  and  constitutional 
disorder. 

Since  the  beginning  of  this  century,  cases  of  diphtheria  have 
been  recorded  from  time  to  time  by  English  physicians.  In  the 
years  1858  and  1859  the  epidemic  attained  its  maximum  in  this 
country,  and  in  two  years  about  20,000  persons  fell  victims  to  it.* 

Symptoms. — The  incubation  period  is  usually  very  short.  "  Ac- 
cording to  Oertels,  the  latest  and  best  writer  upon  the  disease,  it 
may  be  stated  positively'  to  occupy  from  two  to  five  days.  His 
own  experiments  also  show  that  in  from  twelve  to  twenty-four 
hours  after  artificial  inoculation  upon  the  surface  of  wounds,  we 
can  detect  a  grayish-white  discoloration,  a  dirty-grayish  layer, 
and  the  other  signs  of  infection. "t  Dr.  Morell  Mackenzie  has 
given  an  instance  of  a  prolonged  period  of  incubation,  fifteen  days 
elapsing  from  the  exposure  to  contagion  to  the  appearance  of 
diphtheria.:}:  The  disease  creeps  on  very  insidiously,  and  may 
have  advanced  considerably  before  any  complaint  is  made  about 
the  throat.  The  earliest  symptoms  are  chilliness,  weakness,  and 
lassitude,  with  pain  in  the  back  and  limbs,  followed  by  febrile 
disturbance  of  varying  duration.  In  some  severe  cases  the  fever 
is  transient  and  soon  passes  ofi",  but  in  mild  cases  it  is  of  longer 
duration.  Elevation  of  temperature  generally  marks  the  com- 
mencement of  the  disease,  it  may  soon  reach  103°  or  104°,  when 
delirium  is  often  present  ;  but  in  many  cases  the  temperature 
appears  to  fall  as  the  disease  advances,  the  skin  becoming  cold, 
and  the  pulse  slow.  These  symptoms  often  precede  death.  There 
is  headache,  thirst,  and  pallor  of  the  face ;  the  .sleep  is  restless 
and  uneasy,  the  mental  faculties  are  clouded  or  excited ;  the  pulse 
is  almost  always  quick  at  the  beginning  of  the  complaint,  and  soon 
becomes  weak  and  compressible.  Cases  are  recorded  of  unusual 
slowness  of  the  pulse,  and  Dr.  Heslop  mentions  one  in  a  child  of 
five  years  of  age,  where  it  did  not  exceed  forty  beats  a  minute.§ 

*  On  Diplitheria,  by  Dr.  Squire,  Eeynolds's  System  of  Medicine,  vol.  i,  p.  11. 
f  Article  Diphtheria,  Ziemssen's  Cycloi)Eedia  of  Medicine,  vol.  i,  p.  594.    Quoted  hy 
Murchison,  Clin.  Trans.,  1878,  p.  218. 

X  On  Diphtheria,  1879,  p.  19.  \  Greenhow  on  Diphtheria,  p.  211. 

22 


338  DISEASES   OF   CHILDREN. 

The  tongue  is  covered  with  a  thin,  creamy  fur,  or  it  is  quite  clean 
except  at  the  posterior  part.  The  appetite  for  food  is  small,  and 
the  prostration  of  strength  so  great  that  the  patient  is  too  weak 
to  exert  himself  to  take  food,  and  consequently  many  patients  die, 
who  reasonably  might  be  expected  to  recover  if  they  could  take  a 
proper  amount  of  nourishment. 

The  urine  is  pale;  it  contains  urates  or  even  phosphates,  and  at 
an  early  stage  albumen  is  frequently  found.  Albuminuria  is  one 
of  the  most  interesting  features  of  the  disease.  Attention  was  first 
drawn  to  this  symptom  by  Dr.  Wade,  of  Birmingham.*  It  gener- 
ally appears  at  an  early  period  of  the  disease.  It  is  a  frequent 
complication  of  diphtheria,  and  increases  the  danger  to  life. 
"Whether  albumen  is  present  in  large  or  in  small  quantity,  it  is  a 
serious  symptom.  But  albumen  bears  no  relation  to  the  other 
sj-mptoms,  as  it  is  equally  present  in  mild  as  in  severe  cases.  Casts 
of  the  urinary  tubes  do  not  invariably  accompany  the  most  pro- 
fuse albuminuria,!  and  the  albumen  may  disappear  altogether  in 
the  course  of  a  few  days,  as  the  approach  of  convalescence  is 
reached.  Greenhow  remarks  that  he  has  "  several  times  been  un- 
able to  detect  albumen  by  the  proper  tests  in  very  malignant  cases 
of  diphtheria.":}: 

On  looking  into  the  throat,  some  redness  or  swelling  may  be 
observed  on  the  fauces,  pharynx,  and  tonsils;  the  cervical  glands 
are  enlarged  ;  there  is  pain  in  deglutition,  and  stiflfness  of  the 
neck  in  separating  the  jaws.  The  eyes  have  a  heavy,  languid 
look,  and  the  conjunctival  vessels  are  injected  ;  the  nostrils  are  in- 
flamed, or  obstructed  from  swelling  of  the  Schneiderian  membrane, 
or  the  presence  of  a  tenacious  secretion.  Between  the  first  and 
second  day  from  the  commencement  of  the  throat  symptoms,  the 
tonsils  become  more  swollen,  and  a  fibrinous  exudation  can  be  seen 
coating  them,  as  well  as  on  the  back  of  the  pharj-nx,  which  is  now 
turgid,  and  assumes  a  claret  hue.  Over  a  part  of  the  inflamed  sur- 
face, a  tough  la3'er  of  gray -looking  lymph  is  deposited,  resembling 
wetted  chamois  leather  or  damp  parchment,  which  continues  to 
increase  in  thickness ;  in  some  instances  it  is  very  thin  and  super- 
ficial. This  false  membrane  (which  is  pathognomonic  of  the  dis- 
ease) is  not  invariably  of  the  same  color  ;  in  some  cases  it  presents 

*  Midland  Quarterly  .Journal  of  the  Medical  Sciences,  1858. 
f  Greenhow  on  Diphtheria,  p.  204. 
+  Ibid.,  p.  207. 


DIPHTHERIA.  339 

a  clirty  white  or  3'ellowish  appearance ;  in  others  it  is  of  a  brown- 
ish or  ash-colorccl  hue,  and  in  exceptional  cases  it  has  a  blackish, 
gangrenous  look,  and  is  horribly  offensive.*  In  some  cases  the 
exudation  is  first  seen  on  the  soft  palate,  or  on  one  or  both  tonsils, 
but  wherever  it  may  be,  it  either  extends  from  one  part  to  another, 
or  it  simultaneousl}^  appears  on  several  parts  at  the  same  time. 
Spots  of  exudation,  which  at  first  are  separate  and  distinct,  will 
coalesce  and  form  a  continuous  layer  in  a  few  hours.  The  extent 
and  color  of  the  exudation  are  generally  in  proportion  to  the 
severity  of  the  disease.  When  there  is  a  light  and  small  distinct 
patch  the  disease  is  mild  and  runs  a  favorable  course ;  but  when 
the  exudation  is  extensive  or  thick,  or  the  patches  unite  or  form  a 
continuous  layer,  then  the  constitutional  depression  is  great,  and 
the  patient  is  in  imminent  danger  of  his  life.  In  some  cases  cough 
is  a  very  early  symptom.  In  June,  1869,  a  boy,  aged  six  years, 
presented  himself  in  the  out-patient  department  of  the  Samaritan 
Hospital,  whose  illness  began  with  a  slight  cough  on  the  5th.  On 
the  8th,  when  he  came  under  notice,  he  had  a  hoarse  and  frequent 
cough,  and  his  voice  was  subdued  and  husky.  On  the  lower  part 
of  the  pharynx  and  right  tonsil  was  the  characteristic  membrane ; 
the  child  was  very  weak  and  pallid,  the  tongue  coated,  and  the 
pulse  140  and  feeble.  He  made  a  good  recovery,  the  only  sequelae 
being  enlargement  of  the  tonsils. 

"When  the  exudation  has  fully  formed,  it  mingles  with  the  secre- 
tion from  the  mucous  follicles,  and  the  cervical  and  submaxillary 
glands  become  enlarged,  and  the  whole  neck  swells.  The  child  is 
now  much  distressed,  as  there  is  great  pain  in  swallowing,  and  the 
poisonous  secretion  excoriates  the  mouth  and  nostrils.  As  portions 
of  the  deposit  separate  from  the  throat  and  are  coughed  up,  there 

*  "  The  diphtheritic  pseudo-membranes,  or,  to  speak  more  precisely,  the  diphther- 
itic sloughs,  result  from  superficial  gangrene  of  the  mucous  membrane,  which  again 
depends  on  compression  of  its  nutrient  vessels  by  an  interstitial  fibrinous  exudation,  or 
from  swelling  of  the  tissue  elements,  which  are  filled  with  a  cloudy  substance." — Nie- 
meyer's  Practical  Medicine,  vol.  ii,  p.  615. 

Inflammation  is  not  essential  to  the  disease,  according  to  some  authorities  ;  but  this 
is  a  question  which  pathology  ought  to  decide.  Diphtheria  is  distinguished  by  a  pe- 
culiar morbid  condition  of  the  mucous  membrane  of  the  throat  and  tonsils.  A  sero- 
mucous  effusion  is  poured  out  on  the  back  of  the  throat,  which  becomes  changed  into  a 
tenacious  membrane,  followed  by  the  formation  of  another  similar  membranous  for- 
mation, till  a  tough  plastic  layer  is  produced.  The  false  membrane  can  be  raised  from 
the  surface,  which  is  ulcerated  and  bleeding.  The  pellicle  of  false  membrane  is  chiefly 
made  up  of  thickened  epithelium,  coagulable  lymph,  pus,  and  blood-corpuscles. 


340  DISEASES    OF    CHILD  REX. 

is  great  fetor  of  the  breath,  and  sometimes  bleeding  from  the 
mouth  and  nose.  This  exudation  is  tough  and  fibrinous,  and  does 
not  separate  easilj^  except  -svhere  it  is  undergoing  decomposition. 
"When  it  has  separated  it  leaves  a  smooth  bleeding  surface,  on 
which  the  exudation  rapidly  forms  again.  As  the  disease  goes  on, 
the  respiration  becomes  impeded  by  the  obstruction  to  the  entrance 
of  air  through  the  larynx,  producing  diphtheritic  croup,*  and  the 
breathing  is  croupy  and  stridulous.  The  voice  is  muffled  or  reduced 
to  a  whisper,  and  the  eyes  are  staring  and  suffused.  The  vessels 
of  the  neck  are  distended,  and  at  each  inspiration  the  depressions 
above  and  below  the  clavicles  are  sucked  inwards,  and  the  epigas- 
trium is  retracted.  With  these  alarming  symptoms  there  are  also 
pains  in  the  head,  which  the  child  moves  incessantly ;  the  surface 
of  the  skin  is  cold  and  clammy,  and  there  is  extreme  agitation  and 
restlessness.  The  consciousness  becomes  more  and  more  impaired, 
and  the  child  dies  suflbcated  and  exhausted.  Death  ensues  as  in 
fatal  cases  of  croup  from  asphyxia. 

When  the  pharyngeal  afiection  is  acute  and  severe  there  is  great 
j)ain  and  difiiculty  in  swallowing  food,  but  as  the  disease  advances 
the  sensibility  becomes  blunted,  and  there  is  no  complaint  of  pain. 
The  patient  sinks  low  in  the  bed  on  his  back,  and  is  insensible  to 
all  that  goes  on  around  him,  or  he  is  delirious  and  muttering ;  the 
imf)ulse  of  the  heart  against  the  walls  of  the  chest  grows  weaker, 
and  the  pulse  becomes  feeble  and  imperceptible.  In  such  cases 
death  ensues  fi'om  asthenia  or  sj-ncope.  When  laryngeal  s^-mp- 
toms  occur  the  patient  may  die  in  the  course  of  two  days,  but 
when  they  are  absent  death  may  not  happen  for  two  or  three 
weeks.  In  cases  that  recover  convalescence  begins  about  the  second 
week.  "  Of  the  seventy-four  cases  collected  by  the  British  31edical 
Journal^  twenty-six  died — fourteen  from  asthenia,  eight  from  im- 
plication of  the  larynx,  three  from  syncope,  and  one  from  subse- 
quent bronchitis."! 

Causes. — A  specific  poison,  either  generated  within  the  body 
or  external  to  it,  is  the  cause  of  diphtheria,  which  spreads  by 

*  Diphtheritic  croup  is  more  common  in  some  epidemics  than  in  others.  The  dis- 
ease shows  no  uniform  disposition  to  attack  tlie  larynx  and  trachea;  many  cases  have 
terminated  throiigli  slieer  exhaustion,  though  there  has  been  severe  throat  complica- 
tion and  sloughing;  whilst  other  cases,  and  even  .some  epidemics,  liave  been  marked 
by  the  extension  of  the  disease  into  tlie  larynx,  and  the  symptoms  of  croup,  with  the 
throat  and  fauces  comparatively  free. 

f  On  Diphtheria,  by  Dr.  Squii'e,  op.  cit.,  p.  139. 


DIPHTHERIA.  341 

contagion  and  infection.  Sir  W.  Jenner  traces  "diphtheria  (like 
erysipelas)  to  cold  when  the  exposed  person  is  depressed  from 
fatigne,  mental  or  moral  causes,  etc.""'^'  It  spares  no  class  of  the 
community,  affecting  the  poor  as  well  as  the  rich,  when  an  epi- 
demic prevails;  but  it  is  probable  that,  notwithstanding  the  evi- 
dence that  has  been  brought  forward  to  the  contrary,  defective 
drainage,  debility,  and  exhaustion  favor  its  development.  The 
disease  is  not  peculiar  to  any  particular  locality;  it  has  been  as 
prevalent  in  high  and  exposed  situations  as  in  low  and  sheltered 
places;  on  clay  and  damp  soil  and  on  dry  and  light  soil ;  on  richly 
cultivated  soil  and  on  barren  moorland ;  in  the  open  country  and 
in  the  densest  towns. f  It  does  not,  however,  appear  to  be  so 
frequent  in  dry  districts,  where  the  drainage  is  good  and  the  soil 
permeable,  as  in  damp,  marshy  districts  in  the  vicinity  of  water. 
Still  this  does  not  clear  up  the  cause  of  the  epidemic,  for  dry  places 
have  been  severely  visited  and  damp  places  have  escaped.  "In- 
deed, it  is  evident  that  some  other  factor  besides  damp  is  required 
for  the  causation  of  this  disease,  seeing  that  humidity  in  every 
conceivable  form  and  degree  always  exists  in  one  place  or  another; 
whereas  diphtheria  had  been  unknown  as  an  epidemic  in  this 
country  for  three-quarters  of  a  century  previous  to  its  recent 
invasion.  Dampness  must,  therefore,  be  regarded  rather  as  an 
auxiliary  than  as  a  principal  cause  of  the  disease.":}: 

As  to  the  outbreak  in  iSTorth  London,  in  1878,  Mr.  W.  H.  Power 
found  that,  with  regard  to  time,  the  customers  of  milk  retailers 
who  bought  their  milk  of  the  same  proprietor  bore  almost  the 
whole  of  the  brunt  of  the  outburst,  which  first  attracted  attention 
to  the  district,  and  which  was  referred  to  sewer  causation.  It 
seems  probable  that  Mr.  Power's  observations  must  be  regarded, 
in  the  present  state  of  our  knowledge,  as  rather  suggestive  and 
incitive  than  conclusive. 

What  the  exact  nature  or  essence  of  the  disease  is  we  do  not  at 
present  know.  How  the  germs  of  the  disease  are  first  developed, 
whether  they  ever  arise  de  novo  (which  is  not  improbable),  or 
w^hether  the  soil  into  w^hich  they  have  been  introduced  is  peculiarly 
adapted  for  their  growth,  are  questions  which  the  science  of  medi- 
cine has  still  to  deal  with,  but  certain  it  is  that  when  a  person  is 
struck  down  with  the  disease,  he  is  capable  of  contaminating  the 

*  Introductory  Address  before  the  Clinical  Society,  1875. 

t  Dr.  Greenhovv  on  Diphtheria,  p.  12-1.  %  Ibid.,  p.  125. 


342  DISEASES    OF    CHILDEEIS". 

surrounding  air  and  drinking-water,  and  so  of  communicating  the 
disorder  to  others. 

Bretouneau  held  the  view  that  the  atmosphere  could  not  trans- 
mit the  contagion  of  diphtheria.  He  taught  that  the  only  way  iu 
which  it  can  be  contracted  is  by  inoculation — that  the  diphtheritic 
secretion  must  come  in  contact  with  "  a  soft  or  softened  mucous 
membrane,  or  with  the  skin  on  a  point  denuded  of  epidermis."* 
This  is  a  subject  still  open  to  discussion,  but  most  authorities 
agree  that  the  disease  is  contagious,  and  can  be  conveyed  by  the 
atmosphere,  invisible  emanations  from  the  sick,  or  even  from  sewer 
gas. 

Eamily  susceptibility  is  sometimes  very  great.  All  the  members 
of  one  family  may  be  attacked,  whilst  those  of  another  family 
living  under  the  same  roof  may  escape.  Some  may  have  the  dis- 
ease slightly,  and  others  severely ;  the  delicate  succumb  more 
readily  than  the  strong. 

A  correspondent  throws  out  the  hypothesis  that  as  the  disease 
often  spreads  iu  a  family,  and  does  not  extend  to  other  persons 
going  freely  about  the  patients,  "  the  poison  germ  of  diphtheria  is 
modified  by  its  habitat,  becomes  in  fact  a  new  variety  growing 
out  of  and  specially  adapted  to  the  constitution  in  which  it  has 
developed,  and  that  this  contagion  finds  in  the  kindred  constitu- 
tions of  brothers  and  sisters  fit  soil  for  its  growth,  while  it  is  thrown 
off  by  stranger  organisms  to  which  it  is  unadapted."f  Dr.  Alfred 
Carpenter  also  supposes  "that  diphtheria  is  dependent  upon  a  germ 
of  living  matter,  which  is  capable  of  reproducing  itself  when  it 
meets  with  a  congenial  soil."  He  considers  that  there  is  a  close 
analogy  between  it  and  potato  blight ;  the  conditions  which  pro- 
mote the  one  have  also  an  influence  upon  the  other.  He  adds  that 
sulphurous  acid,  locally  and  generally  applied,  is  the  best  applica- 
tion, and  that  the  germs  cannot  grow  in  a  creasote  atmosphere.:}: 

The  clothes  of  a  person  may  be  infected  with  the  poison,  and  he 
may  thus  transmit  the  disease  to  others,  though  he  is  not  laboring 
under  it  himself. 

An  instance  came  under  my  notice  in  November,  1878,  where  a 
little  bo3'  in  health  called  at  a  house  in  which  a  child  was  lying  ill 

*  New  Syd.  Soc.  Trans. 

f  On  the  Contagiousness  of  Diphtheria,  the  Lancet,  Jan.  4th,  1879,  p.  .34. 
X  A  Possible  Predisposing  Cause  of  Diphthei-ia,  Brit.  Med.  Journ.,  Jan.  4th,  1879, 
p.  8. 


DIPHTHERIA.  343 

of  the  disease  ;  he  returned  home,  was  struck  down  with  the  dis- 
ease within  forty-eight  hours,  and  died  on  the  seventh  day.  He 
conveyed  it  to  two  brothers  and  a  sister.  The  little  girl,  eight 
years  of  age,  walked  eight  miles  one  daj^,  was  prostrate  with  the 
disease  on  the  next  day,  and  expected  to  die  on  the  third  or  fourth 
day,  but  eventually  recovered. 

Sequelce. — The  heart  is  prone  to  become  enfeebled,  notwithstand- 
ing the  free  exhibition  of  stimulants  and  the  progress  towards  re- 
covery. Sudden  failure  of  the  pulse  and  circulation  now  and  then 
comes  on,  and  the  weakness  continues  till  death.  Valvular  disease 
of  the  heart  has  been  known  to  result  from  diphtheria.  The  pro- 
cesses involved  in  this  disease  may  bring  about  morbid  changes  of 
the  endocardium  affecting  the  valves.  Dr.  Burdon  Sanderson*  has 
shown  the  identity  of  the  valvular  lesions  after  diphtheria  with 
the  ulcerative  endocarditis  of  Kirlvcs,  well  known  to  result  from 
several  acute  specific  diseases.  Sanderson  continues  by  demon- 
strating what  he  happily  terms  the  "  doubly  infective  character  " 
of  those  forms  of  endocarditis  after  acute  diseases.  They  result 
from  specific  infection,  and  in  turn  produce  morbid  changes  in  the 
organs.  Infective  material  becomes  detaclied  from  the  diseased 
valves,  and  distributed  to  the  kidnej's,  liver,  and  lungs.f  Heiberg 
and  Weigert  go  further,  and  pretend  to  have  discovered  the  very 
fons  et  origo  mali  in  colonies  of  micrococci,  which  they  believe  pro- 
duce the  endocardial  disease. 

Sometimes  the  muscular  system  is  fearfully  depressed,  and  the 
patient  loses  all  power  over  his  limbs,  so  that  he  cannot  support 
himself  or  put  on  his  clothes. 

Diplitheritic  Paralysis. — Authorities  difl:er  as  to  the  nature  of 
this  paral3'sis,  some  regarding  it  as  of  reflex  origin,  and  others  as 
due  to  exhaustion  of  the  cerebro-spinal  centres.  "  The  paralysis 
is  more  deserving_  of  the  name  general  than  any  other  which  I 
know,  for  all  the  physical  powers  are  aflfected,  and  sometimes  the 
mind  is  enfeebled.":}: 

The  affection  generally  comes  on  during  convalescence  from 
diphtheria.     It  appears  to  bear  some  resemblance  to  locomotor 


*  Lectures  on  the  Infective  Processes  of  Diseases,  Lect.  IV,  Brit.  Med.  Journ.,  Feb. 
9th,  1878,  p.  179. 

t  See  Chap.  XLT,  on  Ulcerative  Endocarditis. 

X  Diseases  of  the  Nervous  System,  by  S.  Wilks,  M.D.,  1878,  p.  234. 


344  DISEASES   OF   CHILDREN, 

ataxy,  but  galvanism,  whicli  is  of  uo  use  in  this  disorder,  has  con- 
siderable power  over  diphtheritic  paralysis. 

"  It  is  probable  that  inflammatory  disease  of  the  pharynx,  such 
as  tonsillitis,  general  pharj-ngitis,  putrid  sore  throat,  or  syphilis, 
may  give  rise  to  more  or  less  disturbance  of  the  motor  apparatus 
of  this  region  ;  but  it  is  onlj^  in  diphtheria  that  other  nerve-centres 
sufler,  so  that  this  fact  affords  a  means  of  diflierential  diagnosis. 
The  voice  acquires  a  characteristic  nasal  timbre,  the  modification 
of  certain  articulate  sounds  being  very  characteristic,  owing  to 
the  impossibility  of  closing  the  naso-pharyngeal  passage.  Thus 
rub^  head,  and  egg,  become  r?/?7i,  hent,  and  enk."* 

Syiivptoms. — Frequently  the  muscles  of  deglutition  are  seriously 
involved,  and  the  sensibility  of  the  fauces  is  so  affected  that  there 
is  difficulty  in  swallowing,  and  fluids  regurgitate  through  the 
nose,  or  pass  into  the  larynx.  The  voice  is  weak  and  nasal,  the 
uvula  and  velum  are  relaxed,  the  power  of  expectoration  is  lost 
or  impaired,  mucus  accunmlates  in  the  pharynx,  and  the  taste 
and  smell  are  more  or  less  blunted.  Deafness  sometimes  ensues. 
According  to  the  experience  of  Dr.  Maund,  "the  frequency  of 
these  paralytic  aftections  is  in  inverse  ratio  to  the  severity  of  the 
attack  of  diphtheria." Out  of  tw^o  hundred  cases  at- 
tended in  East  Kent  in  1858  and  1859,  not  more  than  ten  exhib- 
ited an}^  secondary  nervous  sjmiptoms  f 

In  other  cases  the  sight  is  impaired,  but  the  weakness  of  vision 
resulting  from  paralysis  of  the  ciliary  muscles  passes  ofl:'  when  the 
health  is  restored. 

Diphtheritic  ophthalmia  has  been  known  to  occur  in  connection 
with  malignant  diphtheria  of  the  throat  and  air-passages. ;}; 

Occasionally  there  is  a  general  loss  of  sensibility  coming  on 
during  convalescence. 

The  paralytic  symptoms  are  geneyalh'  most  severe  on  that  side 
of  the  body  corresponding  to  the  throat  disorder. 

Paralj'sis  of  the  lower  limbs,  and  wasting  of  the  extremities, 
occur  in  some  cases.  The  upper  extremities  are  rarelj'  atlected. 
Where  the  muscles  of  respiration  are  attacked,  danger  is  imminent. 
The  paralysis  is,  however,  generally  curable,  and  yields  to  treat- 
ment in  time. 

*  Diseases  of  the  Throat  and  Nose,  by  Morell  Mackenzie,  M.D.,  1880,  p.  115. 
t  St.  And.  Grad.  Assoc.  Journ.,  18G9,  p.  89. 

X  Diphtheritic  Ophthahuia,  by  Edward  Kettleship,  St.  Thos.  IIosp.  Ecp.,  vol.  x, 
p.  27. 


DIPHTHERIA.  345 

The  tliree  following  cases,  in  cliildren  of  the  same  famil}',  came 
under  my  notice  in  July  and  August,  IbHO.  They  illustrate  many 
of  the  preceding  observations. 

Case  1. — D.  A ,  a  female  child  nearly  four  years  of  age,  had 

a  severe  attack  of  diphtheria,  with  copious  membranous  deposit 
on  the  tonsils  and  pharynx.  There  was  high  fever,  drowsi- 
ness, and  albumen  in  the  urine  to  the  extent  of  one-sixteenth  of 
the  quantity  passed.  The  albumen  persisted  for  some  weeks. 
The  paralytic  symptoms  that  followed  consisted  in  indistinct 
articulation  and  slight  squinting.  Under  tonic  treatment  the 
recovery  was  perfect. 

Case  2. — H.   A ,  a  healthy  boy,  eight  years  of  age,  had 

membranous  exudation  on  both  tonsils  and  back  of  the  pharynx. 
The  constitutional  symptoms  were  more  severe  than  in  the  pre- 
vious case,  but  there  was  very  little  albumen.  The  paralysis 
consisted  in  double  vision,  squinting,  articulation  almost  gone. 
Could  not  see  black  objects,  but  all  other  colors.  When  walking 
in  the  street,  he  ran  up  against  people  in  passing.  Two  months 
after  this  illness  he  was  quite  well. 

Case  3. — A.  A ,  a  boy,  aged  fourteen,  of  nervous  tempera- 
ment, was  taken  ill  August  8th.  Diphtheritic  membrane  ex- 
tended over  the  arch  of  the  palate,  back  of  pharynx,  and  left  ton- 
sil, thick,  tenacious,  and  wash-leather  like.  Albumen  appeared  on 
the  fifth  day  to  the  extent  of  one-half.  The  two  following  days 
the  urine  w^as  nearly  solid,  then  it  gradually  diminished,  and  tem- 
porarily disappeared  on  September  9th.  It  returned  from  time  to 
time,  and  disappeared  altogether  on  September  20th.  The  paral- 
ysis consisted  in  almost  complete  loss  of  sight,  succeeded  by  double 
vision,  imperfect  articulation,  choking,  and  occasional  fainting. 
An  ophthalmoscopic  examination  showed  hypermetropic  refrac- 
tion, and  thinness  of  choroid.  On  nasal  side,  and  in  substance  of 
disk,  there  were  seen  two  distinct  nodules  of  lymphlike  deposit, 
clear  and  well  defined  ;  vascularity  normal.  The  patient  made  a 
good  recovery. 

Hfemorrhage  from  the  throat,  nose,  and  bronchial  mucous  mem- 
brane occurs  occasional!}^  in  conjunction  with  diphtheria;  also 
eruptions  of  the  skin,  resembling  typhoid  fever  and  measles,  are 
mentioned  by  difierent  observers.  Erj^thema,  urticaria,  and  dark 
claret  spots  like  purpura  have  also  been  noticed. 

Mot  hid  Anatomy. — On  examining  the  bodies  of   children  and 


346  DISEASIS   OF   CHZLDEES". 

adults  v^ho  have  died  of  diphtlieria,  evidences  of  brouehitis  aud 
pneumonia  are  frequently  seen.  In  the  trachea  and  bronchial 
tubes  the  peculiar  membranous  formation  is  found,  and  on  the 
removal  of  the  exudation'the  mucous  membrane  is  seen  congested 
and  excoriated,  and  there  are  small  bloodv  points  similar  to  those 
observed  in  the  fauces.  As  the  disease  descends  into  the  larvnx 
and  trachea,  the  false  membrane  becomes  thin  and  spreads  out 
like  a  transparent  film,  or  the  exudation  is  converted  into  a  thick 
creamy  fluid.  The  false  membrane  has  been  observed  lining  the 
bronchial  tubes  to  the  third  or  fourth  bifurcation.  It  sometimes 
extends  to  the  oesophagus  and  stomach,  which  are  found  red  and 
covered  with  exudation.  The  mucous  membrane  may  be  thick- 
ened or  ulcerated,  and  the  tonsils  gangrenous. 

The  heart  has  been  found  small,  and  its  muscular  tissue  pale; 
cases,  too,  of  fatty  degeneration  have  been  recorded,  and  the 
parietes  have  been  studded  with  black  infiltrated  patches  and 
petechial  spots  from  sanguineous  extravasation.  Fibrinous  coagnla 
sometimes  occur  in  the  cavities  of  the  heart,  as  in  scarlet  fever 
and  the  pneumonia  of  children.  They  may  be  seen  in  the  right 
auricle  or  ventricle,  or  in  all  the  four  chambers  of  the  heart,  of 
firm  consistence,  and  so  adherent  to  the  chordae  tendinece,  that  the 
deposit  must  have  happened  during  life. 

The  kidneys  have  been  found  quite  healthy  after  death,  as  may 
be  ex}:)ected  when  the  urine  has  been  free  from  albumen  during 
life ;  but  careful  microscopical  examination  usually  reveals  some 
change  of  a  special  character.  The  kidneys  are  sometimes  only 
congested  in  simple  cases,  but  where  albumen  has  been  a  f»er- 
sistent  symptom,  some  change  in  the  intratubular  structure  will 
generally  be  found ;  the  tubules  may  be  blocked  with  granular 
matter,  oily  globules,  blood-corpuscles,  and  fibrinous  exudation. 

The  sinuses  and  membranes  of  the  brain  and  venous  system 
generally,  have  been  found  remarkably  full  of  blood.  In  a  fatal 
case  recorded  by  Sir  William  Gull,  and  quoted  by  Dr.  Greenhow, 
the  membranes  of  the  brain  and  spinal  cord  were  in  a  state  of 
suppurative  inflammation.* 

Diagnosis. — The  diagnosis  of  diphtheria  from  croup  is  given  in 
the  previous  chapter. 

I  may  here  quote  an  interesting  passage  from  Xiemeyer  on  the 
anatomical  appearance  of  the  exudation.     "  If  the  larynx  and 

*  On  Diphtheria,  p.  239. 


DIPHTHERIA.  347 

trachea  participate  in  the  disease,  the  croupous,  not  the  diphthe- 
ritic form  of  inflammation  of  the  mucous  membrane  occurs — that 
is,  the  surface  of  the  mucous  membrane  is  covered  with  a  more  or 
less  tough  and  consistent  false  membrame,  which  may  readily  be 
removed,  and  leaves  no  loss  of  substance  after  its  removal.  This 
circumstance  has  induced  some  physicians  to  identify  primary 
genuine  croup,  which  is  due  to  catching  cold,  etc.,  with  croupous 
laryngitis  caused  by  infection  with  diphtheritic  contagion.  I  con- 
sider this  a  false  view.  The  division  of  diseases,  according  to  the 
pathologico-anatomical  changes  they  induce,  is  only  a  makeshift. 
In  all  cases  where,  as  in  genuine  and  diphtheritic  croup,  we  find 
that  two  anatomically  similar  disturbances  of  nutrition  depend  on 
very  different  causes,  we  should  consider  them  as  distinct."*  It 
is  this  similarity  in  the  character  of  the  exudation  between  in- 
flammatory croup  and  diphtheria  which  has  continually  led  ob- 
servers to  consider  them  as  one  and  the  same  disease ;  but  this 
certainly  cannot  decide  the  question. 

The  throat  in  malignant  scarlet  fever  and  diphtheria  is  very 
much  the  same  in  appearance,  and  may  be  confounded  the  one 
with  the  other.  As  regards  tbe  diagnosis  at  tbe  beginning  of 
diphtheria,  the  more  circumscribed  redness  and  the  peculiar  yellow 
patch  of  the  exudation  is,  from  an  anatomical  point  of  view,  so 
characteristic,  that  it  is  conclusive  evidence  of  the  disease.  Yel- 
lowish or  grayish-brown  sloughs  of  plastic  lymph  on  the  tonsils 
and  pharynx,  leaving  later  on  a  bleeding  surface  where  the  mem- 
brane is  removed,  are  common  in  diphtberia  ;  but  in  severe  in- 
stances of  either  disease,  ashy-looking,  gangrenous  deposits  may  be 
seen,  and  owing  to  this  circumstance,  a  diagnosis  would  be  im- 
possible. In  scarlatina,  the  constitutional  symptoms  preceding 
the  throat  affection  are  more  marked,  the  skin  is  pungent  and 
hot,  and  the  temperature  is  high ;  whereas  in  diphtheria,  tbe  throat 
may  be  severely  aftected  in  the  absence  of  these  symptoms,  and 
the  pulse  and  respiration  are  low.  In  both  diseases  the  lymphatic 
glands  are  involved.  The  throat  generally  presents  a  more  uniform 
redness,  and  the  tongue  is  characteristic  in  scarlet  fever.  The 
soft  palate  and  tonsils  have  a  milky  or  creamlike  aspect ;  there  is 
a  thick  layer,  which  soon  clears  off,  leaving  the  parts  beneath 
angry  and  red.     In  diphtheria  the  exudation  is  more  deeply  seated, 

■^  Xiemever's  Practical  Medicine,  vol.  ii,  p.  615. 


348  DISEASES    OF    CHILDREN". 

and  it  comes  off  in  dense  membranous  laj'ers,  representing  a  cast 
of  the  surface  on  which  they  have  formed. 

At  a  verj  earl}^  stage  it  is  not  easy  to  distinguish  the  redness  of 
diphtheria  from  the  inflamed  sore  throat  of  inflammatorj^  catarrh, 
in  which  the  tonsils  are  tumid,  and  have  a  thin  \ayev  of  lymph 
upon  them.  The  pharynx  is  vascular  and  irritable,  and  the  lym- 
phatic glands  are  tender  and  enlarged  ;  but  they  go  down  when 
the  cold  is  relieved.  In  healthy  subjects,  however,  an  inflamed 
state  of  the  cervical  glands  is -exceptional  in  cases  of  tonsillitis.  I 
have  many  times  known  children  with  a  temperature  of  103°,  or 
more,  in  this  complaint,  and  the  throat  so  swollen  and  the  fauces 
narrowed,  that  the  swallowing  of  liquids  was  most  painful,  and 
yet  the  glands  in  the  neck  were  not  enlarged.  When  they  are 
swollen  there  is  fear  of  a  strumous  taint,  and  the  specific  inflam- 
mation is  often  sufiicient  to  excite  chronic  enlargement,  if  not  sup- 
puration. Then  there  is  a  discharge  from  the  nose,  and  the  fever 
is  considerable,  with  thirst  and  difficulty  in  swallowing. 

The  diagnosis  from  tonsillitis  can  generally  be  made  ;  in  the 
latter  affection  the  constitutional  symptoms  are  not  of  the  low  and 
adynamic  type  which  belong  to  diphtheria,  and  one  tonsil  is  more 
affected  than  the  other. 

Scarlet  fever  and  diphtheria  have  prevailed  together  at  the  same 
time  and  place,  and  each  disease  has  exhibited  the  characteristic 
local  symptoms.  One  member  of  a  family  has  had  the  peculiar 
exudation  of  the  fauces,  but  no  rash  or  desquamation  which  occurs 
in  scarlet  fever.  "Sometimes,"  says  Dr.  Greenhow,*  "cases  of 
diphtheria  and  scarlet  fever  have  even  been  intermingled  in  the 
same  family,  or  diphtheria  has  appeared  in  persons  who  have  been 
in  communication  with  patients  sufiering  from  scarlet  fever." 
Another  difference  between  the  two  diseases  is,  that  the  albumi- 
nuria of  scarlet  fever  comes  on  at  a  late  stage,  often  at  the  end  of 
a  week  or  month,  after  the  eruption  has  left,  during  the  period  of 
desquamation,  and  it  goes  on  to  dropsy  and  anasarca  with  ho?ma- 
turia.  In  diphtheria,  albuminuria  is  an  earlier  symptom  when  it 
does  occur ;  hoematuria  is  rare,  and  dropsy  does  not  result,  nor  is 
the  excretion  of  urea  lessened.  The  urine  does  not  present  the 
smoky  appearance  which  is  common  in  scarlet  fever,  but  casts  of 
the  urinary  tubules  are  generally  found. f  The  presence  of  albu- 
men in  the  urine  is  hj  no  means  a  constant  symptom,  even  in 


On  Diplitheria,  p.  102.  t  Ibid.,  p.  2U5. 


DIPHTHERIA.  349 

severe  cases,  but  when  it  is  present  in  large  quantity  it  is  a  serious 
indication.  Anasarca  is  rarely  present  except  in  cases  complicated 
with  scarlet  fever.  Umcmia  has  not  been  observed  in  connection 
with  the  albuminuria  of  diphtheria  ;  but  excess  of  phosphates  and 
urates,  with  high  specific  gravity  of  the  urine,  is  of  common  oc- 
currence.* 

It  has  been  asked  whether  there  is  any  relationship  between 
diphtheria  and  enteric  fever,  and  it  appears  certain  that  the  two 
diseases  are  not  unfrequently  associated.  Dr.  Murchison  considers 
that  it  is  not  true  diphtheria,  the  throat  complication  in  enteric 
fever  being  frequently  found  where  there  is  no  diphtheria.  As  the 
causes  of  the  two  diseases  are  much  alike,  we  should  exjDCct  them 
to  prevail  together,  and  not  look  upon  their  existence  as  a  mere 
coincidence.  Dr.  Greenfield  brought  before  the  Pathological  So- 
ciety (ISTovember  6th,  1877),  a  specimen  of  diphtheritic  membrane 
from  the  larynx  and  pharynx  of  a  child,  aged  five,  who  had  been 
under  the  care  of  Dr.  Murchison  at  St.  Thomas's  Hospital,  sufit'er- 
ing  from  unmistakable  enteric  fever.  There  was  ulceration  of 
Peyer's  patches,  and  also  swelling  and  round  excavated  sloughing 
ulcers  in  the  lower  part  of  the  ileum.  In  addition  there  was 
bronchopneumonia ;  but  no  false  membrane  could  be  seen  on  the 
fauces  or  the  tonsils,  which  were  red  and  swollen. 

As  to  the  communicability  of  the  disease,  it  is  held  to  take  place 
through  the  secretions  of  the  throat  by  Bretonneau  and  others ; 
but  the  experience  of  many  medical  men  during  the  epidemic  of 
1858  and  J 859,  does  not  concur  in  the  opinion  that  the  disease  is 
communicated  in  this  way.f  In  contemplating  the  record  of  cases, 
however,  we  can  hardly  fail  to  observe  that  the  diphtheritic  secre- 
tions have  induced  ophthalmia  and  throat  afitections  in  those  per- 
sons who  have  been  nursing  the  sick,  or  have  seized  upon  the 
medical  attendants  who  have  been  close  enough  to  receive  particles 
of  the  exudation  when  the  patients  have  coughed  or  sneezed  dur- 
ing an  examination  of  the  throat  and  fauces,  or  the  application  of 
some  local  agent.  The  character  of  the  disease  so  induced,  has 
been  in  a  few  instances  that  have  come  within  my  knowledge,  so 
precisely  like  the  diphtheritic  exudation,  that  I  think  the  evidence 
of  propagation  by  contact  with  the  secretion,  cannot  be  set  aside. 
The  disease  has  spread  with  rapidity  in  the  cottages  of  the  poor, 
where  the  appliances  of  the  sick  are  scanty,  and  cleanliness  is  dis- 

*  On  Diphtheria,  p.  208.  f  Ibid.,  p.  137. 


350  DISEASES   OF   CHrLDREX. 

regarded.  Then,  again,  a  child  laboring  under  diphtheria  has  been 
brought  from  a  distance  to  its  own  hon  e,  and  soon  afterwards  the 
disease  has  attacked  other  members  of  the  family,  when  previous 
to  its  return,  not  a  single  case  had  happened  in  the  house,  or  the 
surrounding  district  for  many  miles.  Dr.  Squire  notices  that  the 
more  abundant  the  secretion  in  particular  cases  of  diphtheria  the 
greater  the  danger  of  infection."^ 

I  think  we  shall  be  forced  to  admit  that  diphtheria,  like  tj'phoid 
fever,  has  sometimes  a  spontaneous  origin,  when  soil  and^  season, 
temperature,  filth,  and  uueleanliness  combine  to  lower  the  general 
health  and  contaminate  the  blood.  If  it  were  not  so,  how  shall 
we  explain  the  alarming  outbreaks  of  these  diseases  in  schools  and 
isolated  homes,  and  their  tendency  to  remain  within  a  limited 
area,  and  not  to  spread  in  an  epidemic  form  ? 

The  infection  of  the  atmosphere  by  the  exhaled  air  of  the  sick 
patient,  leaves  no  room  for  doubt  that  this  is  another  mode  by 
which  the  disease  is  propagated.  Children  who  have  been  in  the 
same  house  with  diphtheritic  patients  have  contracted  the  disease, 
when  they  have  not  ventured  near  the  sufferer  ;  and  there  are 
no  doubt  other  vehicles  for  the  transmission  of  the  poison,  subtle, 
tenacious,  mysterious,  ever  ready  to  seize  upon  the  young,  "  The 
greater  frequency  of  the  disease  among  children  than  adults  does 
not  seem  to  be  due  to  greater  predisposition  of  the  former,  but  to 
their  being  more  exposed  to  infection  than  adults  ure."t 

Treatment. — This  is  a  disease  demanding  local  and  constitutional 
measures,  and  from  the  first  neither  should  be  disres^arded.  Some- 
times  the  local  should  be  the  most  energetic,  and  sometimes  the 
constitutional ;  but  from  the  commencement  the  treatment  must 
be  supporting,  if  not  stimulating,  and  those  measures  that  are 
most  to  be  relied  on  in  exhaustion  and  syncope  are  to  be  held  in 
close  reserve.  Like  other  epidemics,  the  disease  does  not  admit 
of  depletory  measures,  and  all  practitioners  who  have  had  a  large 
experience  of  it  insist  upon  the  necessity  of  employing  a  support- 
ing plan  of  treatment.  Each  case  will  require  some  modification 
in  accordance  with  its  peculiarities  and  tendencies,  so  that  it  is 
not  easy  to  lay  down  any  exact  rules  to  follow.  The  patient 
should  be  placed  in  a  large  and  well- ventilated  room,  the  tem- 
perature of  which  should  range  from  60°  to  65°.     He  should  be 

*  Reynolds's  System  of  Medicine,  vol.  i,  3d  edit.,  p.  115. 
f  Niemeyer,  op.  cii.,  vol.  ii,  p.  615. 


DIPHTHERIA.  351 

kept  absolutely  quiet  in  bed,  with  the  head  low,  and  all  excite- 
ment carefully  guarded  against. 

At  the  commencement  of  the  disease,  a  purge  of  calomel  and 
rhubarb  is  sometimes  required,  so  that  some  of  the  poison  may  be 
eliminated  by  the  intestinal  canal.  This  has  been  insisted  upon 
by  Sir  William  Jenner  ;  and  other  observers  have  advocated  this 
treatment  at  the  beginning  of  the  disorder,  when  the  strength  is 
equal  to  it.  Under  most  circumstances,  a  mild  saline  aperient,  to 
keep  the  bowels  regular,  will  be  occasionally  required,  or  a  small 
dose  of  castor  oil ;  still,  caution  must  be  observed  in  the  adminis- 
tration of  aperients.  Our  best  guide  in  this  matter  is  the  mildness 
or  severity  of  the  attack,  for  in  tbe  malignant  form  the  child  is 
overpowered  by  the  poison  at  once,  and  tbe  pulse  is  so  feeble  that 
any  depressing  remedy  would  only  hasten  the  tendency  to  fatal 
syncope.  Milk  in  large  quantities,  beef  tea,  chicken  broth,  and 
eggs  are  the  forms  of  nourishment  best  suited  to  maintain  the 
flagging  strength.  Wine  or  brandy  will  be  almost  invariably 
needed,  and  the  quantity  must  be  regulated  by  the  strength  and 
frequency  of  the  pulse.  Where  there  is  a  tendency  to  syncope  or 
failure  of  the  heart's  action,  or  the  pulse  is  slow,  very  frequent,  or 
irregular,  considerable  quantities  of  alcohol  can  be  taken  with 
advantage.  Perseverance  in  the  administration  of  food  and  medi- 
cine is  imperatively  demanded,  and  the  attempt  must  not  be 
abandoned  under  the  impression  that  the  child  is  unable  to  swal- 
low, for  this  is  constantly  found  to  be  erroneous. 

When  exhaustion  is  the  leading  feature  of  the  case,  the  child 
should  not  be  allowed  to  sleep  too  long  without  nourishment.  If 
the  throat  is  painful,  and  there  is  thirst,  a  piece  of  ice  to  suck  is 
very  grateful  and  refreshing.  A  small  quantity  of  iced  water 
should  be  oftered  frequently  if  the  mouth  and  lips  get  dry  quickly. 
In  the  shape  of  medicine,  the  carbonate  of  ammonia,  with  the 
tincture  of  bark  (Form.  11),  is  an  excellent  combination  for  sup- 
porting the  system  against  exhaustion.  When  the  skin  is  hot 
and  the  temperature  high,  ice,  cooling  drinks,  and  diaphoretics* 

*  Formula  52 : 

R.    Liq.  amm.  acet., ^ij 

Spt.  aether,  nitr., 3j 

Syr.  rospe, ^iij 

■Aquam  ad §iv. — M. 

A  tablespoonfiil  to  be  taken  every  four  hours. 


3£2 


DISEASES   OF   CHILDREN. 


will  be  useful ;  with  these  may  be  combined  the  tincture  of  the 
perchloride  of  iron,*  or  the  iron  may  be  given  alone  or  with  chlo- 
rate of  potash.  In  most  of  the  inflammatory  throat  aiiections  of 
children,  this  preparation  of  iron  has  a  wonderful  effect,  and  is  as 
specific  as  in  erysipelas,  which  may  be  possibly  due  to  some  antisep- 
tic properties  which  it  exerts  locally,  and  possesses  after  its  entrance 
into  the  blood.  It  requires  to  be  given  frequently,  and,  according 
to  some  authorities,  in  large  doses.  A  small  dose  (rrj^v  to  ttj^x), 
with  or  without  the  dilute  hydrochloric  acid,  once  in  four  hours, 
is  often  enough  in  mild  cases.  If  the  tongue  is  furred  and  the 
breath  fetid,  chlorate  of  potash,  in  combination  with  the  acid,  is 
an  excellent  remedy,  and  recover}^  will  take  place  under  its  steady 
continuance.  Quinine,  salicylic  acid,  benzoate  of  soda,  when  the 
temperature  is  high  and  the  system  depressed  by  the  septic  nature 
of  the  disease,  are  all  useful.  When  the  throat  exhibits  dark  and 
softened  portions  of  exudation,  with  a  tendency  to  bleed  when 
touched,  or  there  is  hsemorrhage  from  the  mucous  surfaces,  then 
the  perchloride  of  iron  must  be  combined  with  it ;  and  in  this 
formidable  complication,  a  full  dose  should  be  given  ever}'  hour 
or  two,  till  the  urgent  symptoms  are  relieved.  In  most  cases  I 
prefer  a  mixture  consisting  of  iron,  chlorate  of  potash,  and  hydro- 
chloric acid.f  It  is  particularly  suitable  when  the  exudation  is 
firm,  the  tongue  coated,  and  the  throat  exhibits  no  hemorrhagic 
tendency. 

The  chlorine  drink  recommended  in  scarlet  fever  is  equally  of 
service  here.  It  is  grateful  to  the  little  patients  by  relieving  the 
throat  and  febrile  symptoms  when  they  are  present.  It  also 
possesses  antiseptic  properties,  and  improves  the  character  of  the 
exudation. 

Quinine  and  the  mineral  acids  are  also  useful  variously  com- 


*  Formula  53: 

R-    Tinct.  ferri  perclilor., 

Glycerini,     ......... 

Aquam  ad     ........         • 

A  tablespoonful  every  four  liours.     For  children  five  rears 

t  Formula  54: 

R.    Tinct.  ferri  perchl., 
Pota.ss.  chlorat.,    . 
Acid,  liydrochl.  dil., 
Syrupi, 
Aquam  ad    . 
A  tablespoonful  every  four  hours.     For  children  five  years 


.5J 


;ss. 


6' 
giv. 
of  age. 

^xl 
gr.  xl 
"Kxl 

3  S3. 

Siv.- 
of  age. 


M. 


M. 


DIPHTHERIA.  353 

binecl.  External  applications  to  the  throat,  in  the  shape  of  leeches, 
blisters,  and  counter-irritants,  are  in  no  case  requisite,  and  will  do 
harm.  Warm  poultices,  fomentations,  or  water-dressing,  are  com- 
fortable and  useful. 

The  applications  to  the  throat  internally,  are  those  indicated  in 
scarlet  fever,  and  the  same  precautions  as  to  strength  are  to  be 
observed.  In  3'oung  children  who  cannot  gargle,  a  solution  of 
borax  may  be  applied  to  the  throat  (.53S.  to  the  5j),  or  equal  parts 
of  the  liquor  ferri  perchloridi  and  honey  may  be  used  with  ad- 
vantage. This  is  perhaps  the  best  astringent  application.  In  a 
case  that  came  under  my  care  a  few  years  ago,  a  thick  solution  of 
chlorate  of  potash,  borax,  glycerin,  and  honey,*  gave  much  relief 
to  the  throat.  At  an  early  stage,  when  the  membrane  is  thin  on 
the  fauces  and  tonsils,  a  solution  of  nitrate  of  silver  (gr.  x  or  gr. 
XX  to  the  5j),  applied  with  a  camel-hair  brush,  twice  in  the  twenty- 
four  hours,  has  been  of  benefit.  The  application  of  the  solid  nitrate 
of  silver  must  be  cautiousl}^  resorted  to  ;  indeed,  it  is  questionable 
whether  this  or  any  other  caustic,  as  hydrochloric  acid,  or  the  acid 
nitrate  of  mercury,  is  ever  necessary.  They  increase  the  pain  and 
difficulty  of  swallowing,  and  at  the  same  time  aggravate  the  local 
mischief.  If  there  is  fetor  of  the  breath,  and  the  parts  incline  to 
be  sloughing  and  gangrenous,  the  solution  of  chlorinated  soda,  in 
the  proportion  of  one  drachm  of  the  solution  to  two  ounces  of 
water,  is  an  excellent  application.  This,  and  the  iron  solution,  are 
two  most  valuable  measures,  according  to  my  experience,  in  every 
stage  of  diphtheritic  sore  throat.  Some  children  are  so  alarmed 
and  frightened  at  the  attempt  to  press  down  the  tongue,  and  apply 
applications  to  the  throat,  that  these  measures  had  better  he  given 
up  altogether  in  such  cases.  I^ervous  and  delicate  children  are 
almost  thrown  into  convulsions  by  their  struggles  and  resistance, 
,  and  where  these  applications  cannot  be  used  there  is  consolation 
in  remembering  that  escharotics  are  of  doubtful  efficacy,  and  even, 
according  to  some  English  and  foreign  physicians,  who  have  had 

great  experience  of  the  malady,  decidedly  injurious.      In  diph- 

» 

*  Formula  55 : 

Be.  Potass,  chlorat., 

Boracis,  aa        .  . ^j 

Glycerin!, 

Mellis,  aa gss. — M. 

The  throat  to  be  mopped  out  with  a  little  of  this  solution  frequently  during  the  day. 

23 


354  DISEASES   OF   CHILDREN". 

theritic  afi'ections  of  the  throat,  the  carbolic  acid  spray  will  often 
be  found  very  useful,  just  as  it  is  in  the  faucial  affections  of  scarlet 
fever  and  measles.  Lime-water,  sulphurous  acid,  lactic  acid,  etc., 
have  been  also  used  in  like  manner  with  success.  The  most  con- 
venient plan  of  using  the  spray  is  to  employ  Siegle's  apparatus,  or 
the  hand  spray  of  Dr.  Andrew  Clark. 

As  regards  the  operation  of  tracheotomy  when  death  threatens 
from  suffocation  and  dyspnoea.  Professor  George  Buchauau,  of 
Glasgow,  has  recorded  some  -interesting  cases  of  success.  Out  of 
thirty  cases  he  had  eleven  recoveries.*  He  has  subsequently  in- 
formed me  that  in  every  eight  tracheotomies  performed  on  chil- 
dren practically  moribund  from  suffocative  membranous  effusion 
into  the  trachea,  he  has  saved  three  children,  and  this  is  true  of 
over  fifty  cases  operated  upon.f 

Two  interesting  cases  of  successful  tracheotomy,  in  the  last 
stage  of  diphtheria,  were  brought  before  the  Clinical  Society  by 
Mr.  George  Lawson  and  Mr.  Pugin  Thornton  (Feb.  28th,  1879). 
Two  cases  of  diphtheritic  larjmgitis  have  been  recorded  in  which 
recovery  also  followed  tracheotomy.  The  first  case  was  that  of  a 
boy,  six  years  of  age,  who  was  admitted  into  the  Middlesex  Hos- 
pital, under  the  care  of  Dr  Coupland,  May  30th,  1880.  The  suc- 
cessful issue  was  owing  to  the  operation  having  been  performed 
at  an  early  period  of  the  disease  before  much  false  membrane  had 
formed.  The  second  case  was  also  that  of  a  boy,  seven  years  of 
age,  who  was  admitted  into  the  Children's  Hospital,  under  the 
care  of  Dr.  Gee,  on  Sept.  15th,  1879.  Recovery  followed  quickly, 
notwithstanding  the  extreme  dyspnoea  at  the  tim.e  of  operation, 
and  the  large  quantity  of  membranous  casts  expelled  through  the 
tube  afterwards.:]:  The  following  case  had  a  different  termination, 
owing,  as  I  believe,  to  the  delicate  health  of  the  child,  the  delay 
of  the  operation,  and  the  collection  of  pus  and  false  membrane  in 
the  trachea.  On  June  18th,  1880,  a  female  child,  three  years  of 
age,  was  admitted  under  my  care  into  the  Samaritan  Hospital 


*  Brit.  Med.  Journ.,  1875,  vol.  ii,  p.  293. 

f  A  statistical  table  of  all  the  cases,  with  remarks  on  the  conditions  demanding 
tracheotomy,  will  be  found  in  the  British  Medical  Journal,  vol.  i,  p.  555,  1880. 
"Taking  the  whole  of  the  cases,  the  result  is  that  nearly  two  out  of  every  five  opera- 
tions were  successful ;  and  as  the  operation  was  never  performed  unless  there  was  no 
hope  of  recovery  otherwise,  it  may  be  fairly  stated  that  the  lives  of  these  nineteen 
children  were  saved  by  tracheotomy." 

i  TJie  Lancet,  1880,  vol.  i,  p.  950. 


DIPHTHERIA.  355 

with  diplitheria,  symptoms  of  commencing  laryngeal  obstruction, 
and  great  prostration  of  the  strength.  The  face  was  pale  and  the 
cervical  veins  normal,  but  the  respiration  was  wheezing  and  noisy, 
and  the  cough  frequent  and  laryngeal.  xVir  entered  the  lungs. 
At  4  P.M.  the  child  was  not  so  well,  the  head  was  thrown  back 
against  the  spine,  the  respiration  was  more  embarrassed,  and  the 
epigastrium  w^as  retracted  at  each  inspiration.  Tracheotomy  was 
performed  at  my  suggestion  by  Mr.  Knowsley  Thornton,  the  pa- 
tient being  under  the  influence  of  bichloride  of  methylene.  As 
soon  as  the  trachea  was  opened,  a  teaspoonful  of  purulent  matter 
escaped,  and  the  child  shortly  after  expired  from  shock  and  as- 
phj'xia.  A  post-mortem  examination  revealed  the  upper  surface 
of  the  soft  palate  and  uvula  uniformly  covered  with  diphtheritic 
patches.  Another  patch  lined  the  mucous  membrane  of  the  larynx 
immediately  below^  the  right  vocal  cord  and  projected  into  the 
glottis  ;  a  long  slough  lined  the  mucous  naembrane  of  the  trachea, 
below  the  incision,  extending  almost  to  the  division  of  the  bronchi. 
The  larynx  and  tra<ihea  were  filled  with  purulent  fluid.  Both 
luno;s  were  sli^htlv  congested,  but  floated  in  w^ater;  the  bronchi 
contained  some  purulent  fluid,  but  no  false  membrane.  There  was 
a  large  decolorized  sizy  clot  in  the  right  auricle;  no  abnormal 
appearances  in  the  liver,  mucous  membrane  of  oesophagus,  stom- 
ach, or  intestines.  The  mesenteric  glands  were  much  enlarged, 
but  not  softened. 

A  case  of  diphtheria  in  a  child  is  recorded  by  the  late  Dr.  Mur- 
chison,  in  which  tracheotomy  was  performed  on  account  of  the 
urgent  dyspnoea.  The  points  of  most  interest  lay  in  the  morbid 
changes  found  in  the  intestines.  After  the  operation  a  little  thick 
exudation  was  removed,  with  relief  to  the  breathing.  Death  oc- 
curred in  twenty-five  hours  afterwards.  With  the  return  of  the 
embarrassed  breathing  the  temperature  rose  to  107.6°,  and  at  the 
time  of  death  it  fell  to  104.5°.  The  interior  of  the  larynx  and 
trachea  was  completely  lined  by  a  layer  of  false  membrane,  which 
was  firm  in  some  places  and  easily  detached  in  others.  At  about 
the  fourth  ring  of  the  trachea  it  could  be  separated  in  a  complete 
layer,  beneath  which  the  surface  was  red  and  raw-looking,  and 
"studded  with  minute  vascular  points."  The  larger  bronchi,  as 
far  as  the  third  or  fourth  division,  were  filled  with  a  curdy  fiuid, 
and  some  of  the  smaller  bronchi  were  dilated.  The  state  of  the 
small  intestines  was  the  chief  point  of  interest  in  the  case,  as  the  child 


356  DISEASES  or  children". 

was  said  to  have  been  quite  well  the  day  previous  to  admission. 
The  solitary  and  follicular  glands  of  the  small  intestines  were 
distinct  and  prominent  throughout,  and  there  were  three  or  four 
small  rounded  ulcers  apparently  connected  with  them  at  the  mid- 
dle third  of  the  ileum.  In  the  ileum,  also,  there  were  three  or  four 
ulcers  of  irregular  shape  with  raised  edges,  and  the  Peyer's  patches 
had  undergone  a  change  resembling  that  met  with  in  the  earlier 
stages  of  typhoid  fever.  The  large  intestines  were  healthy.  Both 
lungs  were  collapsed  and  dense ;  the  right  cavities  of  the  heart 
were  distended  with  dark,  perfectly  coagulated  blood.  It  would 
appear  that  although  tracheotomy  temporarily  relieved  the  dis- 
tressing dyspnoea,  no  hope  of  recovery  could  have  been  entertained 
where  the  local  mischief  was  so  extensive  and  the  eftect  of  blood- 
poisoning  had  become  so  general.* 

But  supposing  the  non-identity  of  croup  and  diphtheria  is  ad- 
mitted, and  that  the  diseases  are  in  many  respects  clinically  and 
practically  different,  still  both  are  prone  to  terminate  fatally  by 
exhaustion,  or  by  suffocation  ;  and  these  urgent  symptoms  would 
seem,  at  least,  to  demand  the  same  line  of  treatment.  When  the 
latter  condition  threatens,  and  all  other  remedies  have  proved  use- 
less, we  allow  that  tracheotomy  is  justifiable,  and  that  the  opera- 
tion has  rescued  many  a  little  sufferer  from  an  agonizing  death. 
Henceforth  we  must  look  upon  tracheotomy  in  diphtheria  as  a 
proper  step  to  take  when  the  child  is  beginning  to  struggle  for 
its  breath,  and  the  strength  is  departing ;  when  the  features  are 
livid  from  obstruction  to  the  circulation,  and  the  mischief  is 
limited  to  the  trachea  and  larynx.  If  the  larger  bronchial  tubes 
are  involved  there  will  be  no  objection  to  the  operation;  but  if 
viscid  secretion  is  blocking  up  the  smaller  tubes,  and  there  is  any 
sign  of  pneumonic  consolidation,  then  the  operation  had  better 
not  be  attempted. 

For  the  anaemia  and  nervous  affections  which  follow  diphtheria, 
citrate  of  iron  and  quinine,  the  mineral  acids  and  calumba  (Form. 
14-20j,  should  be  employed.  Strychnia  and  galvanism  are  also 
very  useful  in  diphtheritic  paralysis.  For  any  albuminuria  and 
prolonged  weakness,  the  tincture  of  the  perchloride  of  iron  and 
hydrochloric  acid  are  the  best  remedies.  Change  to  the  seaside  is 
important  in  protracted  cases. 

*  Tlie  Lancet,  vol.  ii,  1873,  p.  771. 


LARYNGISMUS   STRIDULUS.  357 

CHAPTER  XXXL 

LARYNGISMUS     STRIDULUS. 

Synonyms:  Laryngismus  stridulus  {Dr.  Good) — Spasm  of  the  glottis — Croiving  inspira- 
tion or  spasmodic  croup — Child  crowing  (Marshall  Hall) — Spasmodic  or  thymic 
asthma  of  children  (German  writers) — Internal  convulsions — Co7ivulsions  interne 
(Trousseau,  Eilliet  and  Bartliez).  Nature,  Definition,  and  Symptoms — 
Causes:  Predisposing  and  exciting — Cases  in  illustration — General  course  and.  termi- 
nation. Three  Modes  OF  Death  :  1.  From  asphyxia;  2.  From  congestion  of  the 
brain  ai\d  effusion ;  3.  From  exhaustion.  Pathology  :  A  purely  neurosal  affection 
of  the  par  vagum  or  its  branches,  propagating  an  irritation  to  the  muscles  of  the  larynx 
and  throwing  them  into  spasm.  Diagnosis  :  From  croup  and  whooping-cough.  Prog- 
nosis :  Favorable  in  mild  cases  where  the  health  is  good —  Unfavorable  in  severe  cases. 
Treatment  :  Removal  of  exciting  causes — llild  aperients — Belladonna — Bromide  of 
potassium — Quinine  bark — Preparations  of  iron — Cod-liver  oil — Attention  to  diet  and 
general  health. 

This  affection  is  recognized  by  a  peculiar  crowing  noise  which 
takes  place  during  inspiration.  It  is  so  characteristic  that  when 
once  heard  it  cannot  be  forgotten.  It  arises  from  spasmodic  nar- 
rowing, or  temporary  closure  of  the  glottis  and  larynx.  It  is  a 
form  of  internal  convulsion — a  clonic  spasm  of  some  of  the  respi- 
ratory muscles.  As  a  rule,  the  general  health  is  below  a  right 
standard,  and  the  child  is  restless  and  out  of  sorts  before  the 
seizure  happens.  The  disease  is  frequently  associated  with  general 
debility,  atrophy,  or  convulsions. 

It  is  not  uncommon  for  slight  wheezing  and  catarrh  to  precede 
the  development  of  the  symptoms  for  some  days,  but  it  is  not 
usua  lly  attended  by  cough. 

Males  are  more  subject  to  the  disease  than  females.  "  Out  of  my 
fifteen  cases,  eleven  were  boys,  so  that  it  seems  as  if  the  larynx  of 
male  children  begins,  even  in  the  very  earliest  youth,  to  distinguish 
itself  in  form,  or  at  least  in  physiological  activity,  from  that  of 
female  children."* 

Symptoms. — When  a  child  is  seized  with  a  severe  attack  he  strug- 
gles violently,  and  fights  with  his  hands  clenched,  as  if  about  to 
suffer  instant  suffocation  ;  the  face  is  livid  and  congested,  the  eyes 
are  staring  and  suffused,  the  cervical  veins  are  distended,  the  head 
is  thrown  back  against  the  spine,  and  the  whole  body  is  in  tremu- 
lous agitation.     After  about  a  minute  or  two,  and  some  ineftectual 

*  Vogel  on  Diseases  of  Children,  1874,  p.  274. 


358  DISEASES    OF    CHILDREX. 

efforts  to  breathe,  the  spasm  becomes  relaxed,  and  air  passes  down 
the  larynx  with  a  shrill  crowing  sound,  an  indication  that  all  im- 
mediate danger  has  departed.  The  child  now  cries  and  looks 
terrified,  and  then  generally  falls  asleep.  In  exceptional  cases, 
the  feces  and  urine  may  be  j)assed  involuntarily,  but  I  believe  this 
to  be  rare. 

Durino^  the  seizure,  when  the  muscular  stras-o-lino;  is  at  its 
height,  the  thumbs  may  be  noticed  tiglitly  bent  into  the  palms  of 
the  hands,  and  the  toes  turned  inwards  and  towards  the  soles  of 
the  feet.     The  wrists  and  ankles  are  similarly  flexed  inwards. 

It  should  be  remembered  that  all  cases  are  not  equally  severe, 
nor  equally  frequent.  Some  are  milder  than  others,  the  intervals 
are  longer,  and  the  spasms  less  pronounced  ;  the  child  has  a  mild 
attack  of  catching  in  the  breath,  with  slight  and  occasional  crow- 
ing at  long  intervals,  and  then  perhaps  these  synjptoms  pass  off 
altogether  if  the  general  health  improve;  but  if  not,  the  spasms 
ma}'  gradually  increase  in  frequency,  and  several  attacks  occur 
during  the  day.  The  spasms,  which  begin  slightly  in  the  laryn- 
geal muscles,  may  become  more  and  more  severe,  and  in  some 
instances  terminate  in  general  convulsions  and  death.  Under  any 
circumstances,  the  seizures  leave  the  child  exhausted  and  drowsy, 
especially  if  they  are  frequent.  The  attacks  often  come  on  in  the 
night,  or  when  the  child  wakes  out  of  sleep,  or  attempts  to  take 
food  or  drink. 

AVhen  the  bowels  are  disordered,  or  there  are  worms  in  the  intes- 
tinal canal,  some  children  are  liable  to  a  loud,  ringing  cough,  of  a 
purely  nervous  character,  which  alarms  parents.  With  it  there  is 
excited  pulse  and  flushed  face,  but  all  these  symptoms  disappear 
when  an  active  aperient  is  given,  and  the  source  of  irritation  is 
removed. 

The  duration  of  the  disorder  is  uncertain.  In  some  instances  it 
occurs  more  or  less  during  dentition,  and  ceases  when  the  teeth 
have  appeared  ;  in  other  instances  it  slowly  or  suddenly  grows 
worse,  and  ends  in  convulsions  or  asphyxia.  If  the  disorder  recur 
from  time  to  time  it  is  seldom  fatal.  Spasm  of  the  glottis  has 
been  often  assigned  as  a  cause  of  sudden  death  among  infants  and 
young  children,  which  could  not  be  otherwise  explained.  Dr. 
Churchill  says,  "  I  confess  that  I  am  inclined  to  believe  that  many 
of  tlie  deaths  attributed  to  the  nurse  or  mother  overlaying  the 


LARYNGISMUS   STRIDULUS.  359 

child  are,  in  truth,  cases  of  sudden  death  from  spasm  of  the 
glottis."* 

Causes. — These  are  predisposing  and  exciting.  Among  the  for- 
mer are  infancy  and  the  strumous  diathesis;  among  the  latter 
teething  and  worms  in  the  intestinal  canal.  Enlargement  of  the 
bronchial  and  mediastinal  glands  has  been  also  enumerated  as  a 
cause  of  the  ati'ection,  by  pressing  on  the  inferior  recurrent  laryn- 
geal nerve.  "  Laryngismus  has  been  attributed  to  enlargement  of 
the  thymus,  but  this  view  is  not  now  entertained,  one  very  good 
reason  being  that  post-mortem  examinations  show  that  in  many 
instances  there  is  no  enlargement  of  the  organ.  Moreover,  in 
cases  where  a  large  thymus  has  been  found,  there  has  been  no 
laryngismus. "t  Further  than  this,  the  disease  is  rare  in  young 
infants  where  the  thymus  gland  is  largest.  "  M.  Herard  examined 
the  thymus  gland  in  six  children  who  died  of  internal  convulsions, 
and  in  sixty  who  died  of  other  affections,  and  was  not  able  to  dis- 
cover in  its  condition  any  causative  relation  to  this  disease.  In- 
deed, cases  have  been  reported  in  which  the  thymus  had  undergone 
more  than  its  usual  atrophy  at  the  time  when  the  convulsion  oc- 
curred (Hasse).":}:  Though  enlargement  of  the  lymphatic  glands 
in  the  thorax  is  constantly  present  without  causing  the  disease,  I 
cannot  avoid  the  conclusion  that  there  is  some  connection  between 
the  peculiar  shrill  squeaking  cough  when  the  bronchial  glands  are 
enlarged,  and  laryngismus  stridulus.  The  disease  is  more  frequent 
in  damp  and  in  moist  situations  than  where  the  air  is  pure  and 
dry.  It  is  far  oftener  observed  in  towns  than  in  healthy  country 
districts.  It  is  also  said  to  be  sometimes  hereditary,  occurring 
among  families  of  nervous  excitable  persons.  I  have  myself  known 
three  children  of  the  same  family  who  were  ati'ected  with  spasm 
of  the  glottis.  "  There  are  families  in  which  all  the  children  suffer 
more  or  less  from  it,  and  Powell  even  relates  an  instance  where, 
out  of  thirteen  children,  brought  up  by  the  same  parents,  only  one 
escaped  the  disease."§ 

As  to  the  period  of  life  when  the  disease  is  most  common,  we 
may  mention  that  of  infancy,  and  about  the  seventh  month  when 
there  is  disturbance  in  dentition.     After  the  age  of  three  years  it 

*  Diseases  of  Children,  1848,  p.  231. 

f  Reynolds's  System  of  Medicine,  vol.  ii,  p.  260. 

i  Diseases  of  Children,  by  J.  Lewis  Smith,  M.D.,  1869,  p.  194. 

I  Vogel  on  Diseases  of  Children,  1874,  p.  274. 


360  DISEASES   OF   CHILDREN. 

is  much  less  frequent.  "In  31  out  of  37  cases,  of  which.  I  have 
preserved  a  record,  the  symptoms  manifested  themselves  hetweeu 
the  ages  of  six  months  and  two  years,  or  just  at  that  time  wheu 
the  process  of  dentition  is  going  on  with  the  greatest  activity."* 
"  Of  226  cases  which  have  come  under  my  own  notice,  174  were  in 
the  first  year  of  life,  and  the  remaining  52  between  the  second  and 
third  years  ;  and  the  relative  proportion  of  the  sexes  was  150  boys 
to  76  girls.  In  both  parents  and  children  there  was  very  frequent 
evidence  of  rickets. "f  "  In  every  case  of  laryngismus  stridulus 
(save  two)  which  has  come  within  the  experience  of  Sir  W.  Jenner, 
the  child  was  the  subject  of  rickets,":|: 

Most  observers  agree  that  laryngismus  stridulus  is  not  uncom- 
mon in  cases  of  chronic  hydrocephalus,  and  this  has  been  pointed 
out  by  West,  Elsasser,  Vogel,  and  many  others.  Where  the  nerv- 
ous sj'Stem  is  excited  or  exhausted  it  is  sometimes  seen.  I  have 
known  attacks  to  occur  so  often  as  to  convince  me  that  this  is  by 
no  means  an  uncommon  cause.  Fright,  alarm,  emotion,  anger, 
loud  noises,  etc.,  are  all  to  be  enumerated  as  excitants  of  the  seizure. 

The  researches  of  Dr.  Marshall  Hall  elaborately  explain  how 
the  disease  may  originate  through  irritation  of  some  of  the  cranial 
and  spinal  nerves.  "  Spasm  of  the  glottis  is  an  excitation  of  the 
true  spinal  or  excito-motory  system.     It  originates  in 

"  A.  The  trifacial  nerve,  in  teething. 
B.  The  jmeumogastric,  in  over  or  improperly  fed  infants, 
c.  The  spinal  nerves,  in  constipation,  intestinal  disorder,  or 
catharsis. 

These  act  through  the  medium  of 

2.  The  sjnnal  marrow,  and 

3.  A.  The  inferior  or  recurrent  laryngeal,  the  constrictor  of  the 

larynx. 
B.  The  intercostals  and  diaphragmatic,  the  motors  of  respira- 
tion." 
When  the  disease  is  once  established,  a  violent  fit  of  crying,  or 
any  attempts  at  swallowing,  or  sudden  movements  will  bring  it 
on.      Changing  the  nurse   or   giving  improper  food   will  invite 
an  attack  in  a  delicate  child,  especially  if  it  is  the  subject  of  con- 
vulsions, between  which  and  laryngismus  there  seems  to  be  a  close 

*  West  on  Diseases  of  Infancy  and  Childhood,  1859,  p.  181. 
t  Steiner's  Diseases  of  Children,  by  Lawson  Tait,  1874,  p.  129. 
+  Keynold.s's  System  of  Medicune,  vol.  i,  2d  edit.,  p.  823. 


LARYNGISMUS   STRIDULUS.  361 

connection.*  The  following  is  a  fatal  case  in  point :  On  the  27th 
of  January,  1875,  I  was  requested  to  see  the  male  child  of  a  lady 
residino;  in  a  laro-e  and  well-arrano;ed  house  in  the  west  end  of 
London.  He  was  five  months  old,  and  was  horn  strong  and  healthy. 
A  wet-nurse  was  procured  for  the  first  three  months,  when  she 
left,  as  her  milk  was  supposed  to  disagree.  The  child  was  fed 
with  milk  and  Robb's  biscuits,  and  for  a  few  days  before  my  visit, 
"Chapman's  wheat  flour"  was  substituted,  wdiich  appeared  to 
agree.  The  child  had  been  successfully  vaccinated  on  the  25th  of 
December  from  a  healthy  infant,  and  from  this  time  the  mother 
thought  it  had  become  pallid  and  flabby.  The  general  condition 
seemed,  however,  satisfactory,  and  the  pallor  was  probably  due  to 
his  being  shut  up  in  the  house.  There  was  a  large  family  of  chil- 
dren, but  none  of  the  others  had  ever  suftered  from  a  similar  afi:ec- 
tion  or  from  any  illness  of  importance.  On  the  day  previous  to  my 
visit  the  child  was  seized  wdth  what  the  nurse  termed  croup,  being 
unable  to  get  his  breath  for  some  moments,  the  attack  ending  in 
a  crowing  inspiration  and  a  wheezing  cough.  The  child  was  irri- 
table and  restless,  and  could  not  obtain  sleep ;  the  bow^els  were 
sluggish,  and  the  motions  dark  and  offensive.  I  prescribed  a 
powder  consisting  of  bicarbonate  of  soda  and  rhubarb  every  night, 
and  a  mixture  of  bromide  of  potassium  and  sal  volatile  three 
times  a  day.     The  child  to  be  fed  on  cow's  milk  only. 

January  28th,  9  a.m. — I  received  a  note  to  say  that  the  child 
had  had  four  convulsions  since  my  last  visit.  The  nurse  had  car- 
ried him  in  her  arms  all  the  night,  and  if  she  attempted  to  put 
him  down  he  could  not  breathe.  The  seizures  were  marked  by 
fixed  eyes,  pallor  of  cheeks,  darkness  of  the  lips,  and  a  convulsive 
movement  of  the  body,  ^ome  of  these  attacks  ended  in  a  long 
crowing  inspiration.  When  I  approached  the  child  at  my  visit  he 
seemed  almost  electrified,  starting  in  the  nurse's  lap,  and  looking 
dreadfully  alarmed.  There  was  some  coryza,  with  running  of  the 
nose  and  eyes  ;  the  skin  was  moist  and  warm  ;  temperature  100°, 
pulse  156  ;  respirations  36,  noiseless.     At  3.30  a.m.  the  bowels  had 

*  "  Out  of  50  cases  of  laryngismus,  of  which  I  hfive  notes,  19  had  had  eclamptic 
fits." — Dr.  Gee,  St.  Bartholomew's  Hospital  Reports,  vol.  iii. 

"The  occurrence  of  general  convulsions  in  connection  with  laryngismus,  indicates 
that  the  morbid  action  extends  to  and  involves  some  larger  group  of  nerve-cells  than 
in  the  local  spasm,  probably  either  the  whole  of  the  medulla  oblongata,  or  the  corpora 
qnadrigemina  also." — On  Functional  Nervous  Disorders,  J.  C.  Handfield  Jones,  M.B., 
1870,  p.  031. 


362  DISEASES   OF   CHILDREN. 

acted  well,  the  motion  being  of  a  light-yellowish  ochrej  color, 
with  slimy  discharge.  The  food  ordered  to  consist  exclusively  of 
two  parts  of  cow's  milk  and  one  of  sweetened  barley-water.  In 
the  shape  of  medicine,  a  mixture  consisting  of  citrate  of  potash, 
bromide  of  potassium,  and  tincture  of  henbane. 

12  M. — Sleeping  tranquilly,  but  on  being  touched  he  started 
convulsively  ;  there  had  been  one  attack  of  crowing  since  my  last 
visit.  At  5  P.M.  he  was  sleeping,  and  there  had  been  no  return 
of  the  crowing  ;  at  9  p.m.  he  was  resting  in  his  mother's  lap  ;  the 
face  was  calm  and  peaceful ;  the  skin  cool;  pulse  120. 

29th,  9  A.M. — The  bowels  had  acted  moderately  three  times, 
but  the  child  was  continually  drawing  up  his  legs  and  crying,  as 
though  in  pain ;  there  had  been  no  sickness  and  no  convulsion. 
He  was  rather  pale  ;  pulse  120,  respirations  32  ;  the  skin  was  cool, 
and  the  breathing,  as  ascertained  by  putting  the  ear  to  the  back 
of  the  lungs,  was  unembarrassed  ;  the  pupils  were  normal,  and  he 
looked  round  intelligently.  I  considered  he  was  likely  to  recover. 
I  went  downstairs,  and  just  as  I  had  reached  the  hall  I  was  sum- 
moned again,  when  the  mother  handed  me  the  child,  whose  lips 
and  face  were  now  dark,  his  limbs  relaxed,  and  he  had  ceased  to 
breathe.  Death  must  have  taken  place  in  a  minute  from  as- 
phyxia. 

Cases  are  sometimes  to  be  met  with  of  a  more  chronic  character, 
and  where  there  is  no  immediate  danger  to  life. 

Case  2. — On  x\pril  12th,  1875,  a  female  child,  fifteen  months 
old,  came  under  my  care  at  the  Samaritan  Hospital,  which  had 
sufiered  more  or  less  from  laryngismus  ever  since  she  was  six 
months  old.  The  child  was  rickety,  with  the  strumous  diathesis 
strongly  marked,  the  head  was  large,  and  the  anterior  fontanelle 
wide  and  prominent;  the  veins  were  distended  over  the  scalp;  the 
face  was  pale  and  flabby,  and  there  were  only  six  teeth.  Three 
months  before  I  saw  the  child  she  had  had  convulsions,  which 
continued  more  or  less  for  some  time.  The  child  was  often  breath- 
less, the  respiration  habitually  accelerated,  and  the  cough  croupy. 
If  excited  in  any  way,  as  playing  with  other  children,  the  attack 
was  certain  to  occur,  and'so  bad  was  it  that  her  mother  thought 
she  would  sometimes  die  in  it,  as  her  face  became  dark  and  pur- 
ple. Sudden  changes  of  weather,  as  from  heat  to  cold,  or  the 
reverse,  were  certain  to  invite  a  seizure.  H  sometimes  came  on  in 
the  night.      The  mother  stated  that  she  had  suckled  the  child, 


LAEYNGISMUS   STRIDULUS.  363 

having  had  plenty  of  milk,  but  her  health  was  delicate  ;  and  till 
within  a  short  period  she  had  scarcel}^  ever  given  her  any  other 
form  of  nourishment.  The  child  made  a  fair  recovery,  hut  re- 
mained delicate  when  I  saw  her  a  year  after  first  coming  under 
treatment. 

Death  may  tal<e  place  (1)  from  asphyxia,  as  in  the  first  case 
related,  where  the  cavities  of  the  heart  are  full  of  blood,  and 
the  lungs  engorged  ;  (2)  from  cerebral  congestion  and  serous  eftu- 
sion  ;  (3)  from  exhaustion  and  failure  of  the  vital  powers.  "  The 
sudden  death,  which  is  by  no  means  uncommon  in  this  disease, 
depends,  I  conceive,  on  the  transmission  of  irritation  along  the 
cardiac  fibres  of  the  vagi  to  the  heart,  which  is  then  arrested  in 
its  action,  just  as  when  the  pneumogastrics  are  strongly  galvan- 
ized."* 

Pathology. — The  disease  appears  to  depend  primarily  on  irri- 
tation of  the  pneumogastric  nerves,  which  is  provoked  by  disease 
of  the  cervical  or  bronchial  glands,  or  by  irritation  of  the  fifth 
nerve,  as  from  teething,  or  by  disorder  of  the  stomach  and  intes- 
tines. 

The  irritation  is  propagated  to  the  inferior  or  recurrent  laryn- 
geal nerve,  and  the  muscles  of  the  larynx  are  thrown  into  spasm. 
The  larynx  is  entirely  free  from  inflammation,  and  there  is  no 
lesion  of  its  mucous  membrane.  It  is  a  purely  neurosal  aflection, 
and  whatever  anatomical  changes  may  be  found  after  death  are 
in  most  cases  consequences, rather  than  causes,  of  the  seizure.  "It 
seems  rather  to  be  an  independent  afiiection  of  the  par  vagum,  or 
of  its  recurrent  branch,  due  either  to  pressure  along  some  part  of 
the  course  of  one  of  these  nerves,  or  to  centric  irritation  at  the 
root  of  the  vagus ;  or  else  we  may  be  compelled  to  regard  its 
exalted  sensibility  as  a  reflex  phenomenon  arising  from  excite- 
ment of  some  other  nervous  trunk.  In  most  cases  the  pathogeny 
of  this  disease  is  obscure."f  Dr.  West  likens  the  disease  to  hys- 
terical fits  in  the  female,  and  says  that  both  aflections  are  most 
common  when  the  processes  of  life  are 'most  active. :{:  In  some 
cases,  efi:usion  into  the  ventricles,  congestion  of  the  brain,  or  even 
tumors  in  the  cerebral  substance,  have  been  found  after  death. 

*  Handfield  Jones,  M.B.,  op.  cit.,  p.  633. 

f  Niemeyer's  Practical  Medicine,  1875,  vol.  i,  p.  51. 

+  Op.  cit.,  p.  181. 


364  DISEASES    OF    CHILDREN. 

Tubercle  of  the  lung  and  bronchial  congestion  have  been  also 
noticed.     Still  morbid  appearances  are  sometimes  entirely'  absent. 

The  diagnosis  from  croup  is  given  in  the  chapter  under  that 
heading  (page  329),  but  it  may  be  here  stated  that  in  larjmgismus 
the  suddenness  of  the  seizure  and  its  departure,  the  normal  breath- 
ing in  the  intervals  of  the  attacks,  and  the  absence  of  fever  and 
inflammation,  are  the  distinguishing  features  of  this  peculiar  com- 
plaint. As  the  disease  increases  there  is  a  disposition  to  general 
convulsions,  whilst  these  occur  only  in  the  last  stage  of  croup. 
The  crowing  sound  is  not  unlike  that  of  whooping-cough,  but  in 
larj'ugismus  there  is  no  expectoration,  nor  vomiting,  nor  catarrh 
in  the  strict  sense  of  the  term. 

The  prognosis  may  be  considered  generally  favorable  in  slight 
cases,  when  the  seizures  are  not  frequent,  the  health  tolerably 
good,  and  there  is  no  complication.  When  the  case  is  mild,  and 
the  crowing  comes  on  at  long  intervals,  it  usually  jnelds  to  judi- 
cious treatment.  Still,  the  disease  is  always  to  be  regarded  with 
anxiet}^,  and  especially,  if  severe,  from  the  liability  to  cerebral 
complications,  convulsions,  or  sudden  death.  "  Out  of  fifteen 
cases  of  which  I  have  kept  a  record,  eight  died.  Eilliet  and 
Barthez,  out  of  nine  cases,  and  Herard  out  of  seven,  observed  in 
each  only  one  single  instance  of  recovery."* 

Treatment. — The  first  indications  are  to  remove  all  exciting 
causes.  If  the  bowels  are  disordered  they  should  be  set  right  as 
soon  as  possible  by  proper  aperients,  and  healthy  digestion  pro- 
moted. If  the  child  has  taken  a  heavy  meal,  or  indigestible  food, 
an  emetic  may  be  advisable ;  and  should  the  gums  be  swollen  and 
dentition  appear  to  invite  the  complaint,  they  ought  to  be  scarified. 
The  child  should  occupy  an  airy  apartment,  and  noise  and  excite- 
ment be  precluded.  If  seen  during  the  paroxysm  it  should  be  kept 
in  an  upright  position,  and  the  windows  opened,  so  that  it  may 
be  encouraged  to  breathe.  In  severe  cases,  especially  if  a  convul- 
sion threaten,  it  may  be  immersed  in  a  warm  bath,  whilst  cold 
water  is  sprinkled  at  the  same  time  over  the  face.  Dr.  Morley 
Eooke  recorded  a  case  of  laryngismus  stridulus  in  a  child  nine 
months  old,  where  occlusion  of  the  larynx  during  the  fit  produced 
symptoms  like  those  of  a  "  recently  drowned  person."  The  little 
patient  "showed  no  signs  of  life"  when  first  seen  in  the  seizure; 
the  lips  were  blue  and  swollen,  the  face  a  livid  gray,  and  the  ej^es 

■"  Vogel,  op.  cit.,  p.  272. 


LARYNGISMUS   STRIDULUS.  365 

half  closed  and  glassy.  Dr.  Rooke  thrust  his  finger  between  the 
teeth  to  the  fauces,  when  the  child  gave  a  short  heave  and  a 
gasp;  on  repeating  the  movement  inspiration  took  place,  and  in  a 
few  more  seconds  breathinof  ensued.  On  two  more  occasions,  when 
occlusion  of  the  larynx  was  equally  severe,  a  similar  manoeuvre 
brought  round  the  child.  This  is  a  mode  of  treatment  well  worth 
bearing  in  mind  when  the  child  threatens  to  die  from  spasm  of 
the  glottis.  The  cure  was  completed  by  bromide  of  potassium, 
which  was  taken  for  eleven  months.*  Dr.  Wardell  also  points 
out  the  beneficial  eftect  of  "rotating  the  finger  in  the  throat "  in 
these  cases ;  it  induces  an  attempt  to  vomit,  when  the  laryngeal 
muscles  become  relaxed,  and  air  is  admitted  into  the  trachea.  He 
says  it  is  the  first  thing  to  be  done,  and  he  has  seen  it  succeed 
when  death  seemed  imminejot.f 

In  extreme  cases,  where  death  threatens  from  asphyxia,  the 
operation  of  tracheotomy  should  be  employed.  The  inhalation  of 
chloroform  has  been  recommended  in  some  cases,  but  then  its 
influence  soon  passes  ofl^",  and  it  cannot  be  said  to  have  any  cura- 
tive effect.  When  there  is  much  restlessness,  and  the  child  can 
obtain  no  sleep,  the  excitability  of  the  nervous  centres  must  be 
calmed,  and  for  this  purpose  small  doses  of  morphia  may  be 
cautiously  employed.  In  the  intervals  of  the  seizures  the  bowels 
must  be  kept  freely  open,  so  as  to  remove  all  sources  of  irritation 
that  might  sympathetically  excite  spasm. 

Among  the  chief  drugs  are  belladonna,  in  the  form  of  extract 
or  tincture,  which  sometimes  has  the  eifect  of  diminishing  the 
glottic  spasm,  but  in  many  cases  it  fails  altogether.  Bromide  of 
potassium  is  very  serviceable,  given  with  citrate  of  potash,  sal 
volatile,  or  quinine,  according  to  the  peculiarities  of  each  case.:{: 
Carbonate  of  ammonia,  henbane,  bark,  and  mild  preparations  of 
iron,  as  the  ammonio  citrate,  or  the  syrup  of  the  iodide  are  reme- 
dies to  be  selected.  If  the  child  is  strumous  and  rickety,  or  in 
any  way  delicate,  cod-liver  oil  is  invaluable. 

*  Brit.  Med.  Journ.,  1868,  vol.  i,  p.  370. 

t  Ibid.,  p.  474. 

X  Formula  56 : 

R.  Potass,  bromid., gj 

Tinct.  quinise, ^ij 

Glycerini, ^ss. 

Aquara  ad  .........     3J. — M, 

A  teaspoonful  three  times  a  day.     For  a  child  one  year  old. 


366  DISEASES   OF   CHILDEEN. 

Diet  is  of  great  importance,  and,  when  carefully  selected,  the 
disease  may  disappear  without  drugs.  If  the  child  is  fed  at  the 
breast  it  is  sometimes  advisable  to  change  the  nurse,  or  to  give 
cows'  or  asses'  milk.  If  older,  the  food  must  be  light  and  nutri- 
tious, and  given  frequently  in  small  quantities.  The  clothing 
should  be  warm,  and  if  the  child  is  not  too  ill  he  ought  to  be  taken 
out  in  the  open  air  daily.  Sponging  the  child's  chest  with  cold 
water  may  be  practiced  with  advantage. 


CHAPTER    XXXII. 

PERTUSSIS   OR   WHOOPING-COUGH. 

An  infectious  disease  common  in  early  life — Sometimes  happening  a  second  time,  and  in 
adult  or  advanced  age — Nature  and  pathology— Three  stages — 1.  The  catarrhal — 2. 
The  spasmodic — Symptoms  of  each  stage — Injiuence  of  peripheral  irritation — Ulcers  on 
thefrccnum  linguce — Pulmonary  and  cerebral  complications — Bronchitis — Pneum-onia — 
Emphysema — Collapse  of  lung — Tuberculosis— Convulsions — Enlarged  bronchial  glands 
— 3.  The  last  or  terminal  stage.  Treatment  :  Difficulty  in  prescribing  any  plan  for 
general  adoption — Occasional  utility  of  loccd  bloodletting  in  cerebral  and  pulmonary  con- 
gestion— Emetics  in  loaded  bronchi — Importance  of  attention  to  diet,  which  should  be 
light  and  nutritious — Dr.  Fuller's  plan  of  treatment — Sidphate  of  zinc — Zinc  and  bel- 
ladonna— Sulphate  of  atropia — Cannabis  indica— Hydrate  of  chloral — Croton-chloral 
— Bromide  of  potassium — Alum — Nitric  acid — Hydrocyanic  acid — Hydrocyanic  acid 
and  quinine — Carbonate  of  potash — Topical  remedies  to  larynx — Carbolic  acid  inhala- 
tion and  spray — QuJnine  and  bromide  of  potassium,  in  the  neurosal  stage — Change 
of  air. 

Whooping-cough  is  an  infectious  disease  of  early  life,  varying  in 
duration  from  a  few  weeks  to  many  months.  It  is  characterized 
by  a  peculiar  paroxysmal  cough,  and  irritation  or  intlammatiou  in 
the  lining  membrane  of  the  air-passages.  Sometimes  whooping- 
cough  prevails  as  an  epidemic,  and  sporadic  cases  are  common  at 
all  periods  of  the  year  ;  sometimes  the  attacks  are  mild,  and  some- 
times they  are  highly  dangerous  to  life.  It  may  attack  verj^  J^oung 
infants  ;  but  children  between  the  ages  of  one  and  seven  are  most 
liable  to  it.  The  mortality  appears  to  be  greater  among  females 
than  males.  It  may  be  complicated  with  pulmonary  or  cerebral 
disease,  or  it  maj'  run  its  course  from  beginning  to  end  with  much 
spasmodic  cough  and  scarcely  any  bronchial  affection.  In  two  or 
three  instances  I  have  met  with  the  disease  occurring  a  second 


PERTUSSIS   OR   WHOOPIXG-COUGH.  367 

time,  and  snch  is  also  tlie  experieuce  of  other  observers.  A  lady, 
whom  1  have  seen  professionally  for  many  years,  assures  me  that 
she  had  whooping-cough  when  a  child,  and  a  second  and  very 
tedious  attack  when  over  forty  years  of  age.  The  late  Sir  John 
Forbes  had  an  attack  of  whooping-cough  about  a  year  before  his 
death.  Dr.  Easton,  of  Norfolk  Crescent,  has  kindly  furnished  me 
with  the  details  of  two  very  remarkable  cases  that  came  under  his 
care.  The  first  case  was  that  of  a  gentleman  in  his  seventy-first 
year,  who  resided  in  the  West-end  of  Loudon.  On  April  14th,  1869, 
Dr.  Easton  was  consulted,  lie  ascertained  that  the  patient  had 
had  a  cough  for  a  week,  which  resisted  the  usual  domestic  reme- 
dies. The  cough  increased  in  frequency  and  severity,  and  on  the 
18th  he  first  whooped  distinctly.  On  the  llth  of  May  he  was  well 
enouo-h  to  leave  town.  During  the  attendance  he  had  shown  un- 
mistakable  symptoms  of  whooping-cough,  the  paroxysms  occurring 
very  frequently,  and  being  often  followed  by  vomiting.  On  April 
24th,  whilst  in  attendance  on  this  patient.  Dr.  Easton  was  sum- 
moned to  see  Mrs.  P ,  in  her  94th  year,  the  mother  of  the 

above.  She  had  been  in  the  habit  of  receiving  daily  visits  from 
her  sou,  from  whom  she  no  doubt  had  caught  the  disease.  She 
had  a  spasmodic  cough,  which  gradually  increased,  and  in  a  few 
days  she  had  also  well-marked  symptoms  of  pertussis.  The  cough 
continued  until  the  24th  of  May.  These  patients  had  not  pre- 
viously suffered  from  the  disease  to  their  knowledge. 

As  to  the  nature  and  origin  of  the  disease,  a  wide  difference  of 
opinion  prevails.  In  the  earlier  stages  of  simple  and  uncompli- 
cated cases,  nervous  irritation  holds  a  very  prominent  position  in 
the  chain  of  causation,  and  this  appears  to  be  the  opinion  of  most 
writers.  Some  have  ascribed  the  source  of  mischief  to  the  stomach, 
others  to  the  lungs,  and  others,  again,  to  the  phrenic  and  pneumo- 
gastric  nerves.  Dr.  Copland  attributed  the  seat  of  irritation  to 
the  medulla  oblongata  and  base  of  the  brain,  whilst  by  some,  the 
nervous  system  generally  has  been  considered  at  fault.  That  in 
many  cases  the  pneumogastric  nerves  are  the  seat  of  great  irrita- 
tion, and  that  the  brain  is  involved  through  the  medium  of  the 
sympathetic,  is  certain  ;  but  whether  they  are  primarily  or  essen- 
tially concerned  in  the  production  of  the  peculiar  phenomena  ap- 
pears to  me  doubtful.  Whooping-cough  depends  on  a  materies 
morbi  in  the  blood,  having  a  special  affinity  for  the  larynx  and 


368  DISEASES   OF   CHILDREN. 

organs  of  respiration.*  It  has  a  tendency  to  throw  the  muscles  of 
the  glottis  into  violent  spasm,  through  irritation  of  the  inferior 
laryngeal  nerves,  which  not  only  prevents  the  expulsion  of  the 
mucus  so  largely  secreted  by  the  windpipe  in  this  affection,  but 
by  the  violence  of  the  coughing,  and  the  extension  of  the  irritation 
to  the  main  trunk  of  the  pneuraogastric,  affects  the  stomach  and 
causes  vomiting. 

The  latent  or  iyicuhation  period  may  last  from  one  to  three  weeks. 
Dr.  Squire  estimates  it  about  a  week,  and  Dr.  Bristowe  about  a 
fortnight. 

The  disease  may  be  said  to  have  three  stages  : 

1.  The  catarrhal. 

2.  The  spasmodic. 

8.  The  terminal  or  last  stage. 

1.  The  catarrhal  stage  is  usually  ushered  in  with  most  of  the 
symptoms  of  a  common  cold,  such  as  languor  and  febrile  disturb- 
ance ;  but  it  should  be  borne  in  mind  that  the  spasmodic  stage  may 
sometimes  precede  it,  and  the  whoop  be  heard  before  any  bronchial 
irritation  can  be  detected.  The  child  is  peevish  and  restless  at 
night,  the  nose  furnishes  a  slight  discharge,  and  sneezing  and 
tickling  cough  soon  succeed.  It  is  the  severe  and  paroxysmal 
character  of  the  cough  during  this  period,  with  a  persistent  rest- 
less and  feverish  state,  that  suggest — in  the  absence  of  genuine 
bronchitis  symptoms — the  approach  of  pertussis.  The  cough  for 
some  days  may  be  hard,  frequent,  and  irritating ;  but  there  is 
neither  distinct  whoop  nor  expectoration.  Until  the  whoop  occurs 
we  are  in  ignorance  as  to  the  nature  of  the  disease ;  while  even 
if  we  were  not  in  ignorance,  we  should  still  be  without  any  specific 
to  cut  it  short  or  ward  it  off. 

2.  The  spasmodic  or  characteristic  stage  is  recognized  by  an  in- 
crease in  the  frequency  and  severity  of  the  cough,  and  a  change  in 
its  character.  The  fit  of  coughing  is  painfully  prolonged  and 
spasmodic  ;  the  little  sufferer  opens  his  mouth  wide,  as  though  he 

*  The  Registrar-General  includes  whooping-congh  among  the  principal  diseases  of 
the  zymotic  class.  Like  small-pox,  measles,  and  diphtheria,  scarlet  fever,  and  typhoid 
fever,  its  prevalence  is  sometimes  great  and  fatal.  Thus,  of  1322  deaths  registered  in 
I^ondon  for  the  week  ending  May  22d,  1875,  2  died  from  small-pox,  23  from  measles, 
31  from  scarlet  fever,  14  from  diphtlieria,  91  from  wiiooping-cough,  25  from  different 
forms  of  fever,  and  15  from  diarrhfca,  so  that  of  these  201  deatiis  from  zymotic  diseases, 
nearly  half  arose  from  fatal  cases  of  wliooping-cough. 


PERTUSSIS   OR   WHOOPING-COUGH.  3G9 

were  choked  ;  there  is  an  attack  of  vomiting  with  it,  and  the  escape 
of  some  phlegm  and  mucus  from  the  air-passages.  Before  the 
seizure  comes  on,  the  chikl  seems  as  if  he  were  inwardly  struggling 
to  suppress  it,  and  he  has  a  ver}^  anxious  aspect.  When  the  cough 
once  really  begins,  the  eyes  are  swelled  and  bloodshot/'"  and  tears 
run  down  the  cheeks  ;  the  lips  are  bluish,  and  the  face  has  a  pallid, 
bloated  look;  the  veins  of  the  forehead  and  neck  are  distended, 
owing  to  temporary  arrest  of  the  circulation  through  the  lungs, 
the  pulse  and  respiration  are  much  increased  in  frequency.  When 
the  cough  is  very  severe  the  child  may  bleed  from  the  mouth  and 
nose,  owino'  to  the  turo;id  and  cono-ested  state  of  the  mucous  mem- 
brane.  In  consequence  of  the  extreme  distension  of  the  capillary 
bloodvessels,  they  rupture.  Hfemorrhage,  indeed,  from  the  mouth 
during  the  congestive  stage,  when  the  cough  is  severe  and  pro- 
longed, is  extremely  common,  and  will  recur  for  weeks  together 
in  some  cases.  "  In  certain  instances  haemorrhage  may  take  place 
within  the  cavity  of  the  tympanum  in  the  same  manner  and  from 
the  same  cause  as  in  the  nose,  mouth,  and  eyes.  If  the  blood  be 
not  absorbed  suppuration  is  liable  to  ensue ;  and  subsequently 
ulcerative  destruction  of  the  tympanic  membrane,  as  occurs  in 
scarlet  fever."t 

The  attacks  are  usually  worse  at  night,  and  when  they  come  on 
the  child  maj'  get  out  of  bed  alarmed,  and  in  terror  run  round  the 
room  in  a  breathless  state.  Sometimes  the  child  cannot  lie  down 
from  fits  of  sutibcative  cough,  nor  get  any  rest  at  night.  It  is  not 
unusual  to  meet  with  a  child  suff"ering  from  most  of  the  physical 
and  general  signs  of  bronchitis  in  whom  the  poison  of  whooping- 
cough  is  not  suspected,  because  the  whoop  has  not  been  heard. 
This  cough  may  last  when  the  bronchitis  improves,  and  be  attended 
with  violent  and  continuous  expiratory  efforts,  when  the  look  of 
the  child's  face  and  the  nature  of  the  cough  (coming  on  in  parox- 
ysms, especially  at  night)  are  characteristic  of  pertussis.  Nothing- 
is  absent  but  the  whoop.     This  may  develop  itself  further  on,  or 

*  In  1878,  a  boy  aged  eleven  years,  of  robust  frame,  came  under  my  care  with 
whooping-cough.  From  the  extreme  violence  of  the  paroxysms,  a  large  effusion  of 
dark  blood  took  place  in  the  left  antei'ior  chamber  of  the  eye,  only  leaving  a  mere 
speck  of  the  white  sclerotic  at  its  upper  part.  There  was  considerable  bronchial  irri- 
tation, and  some  receut  emphysema. 

t  Haemorrhage  from  the  Ears  in  Whooping-cough  ;  its  real  cause,  by  George  D. 
Gibb,  M.D.,  Brit.  Med.  Jour.,  1861,  vol.  ii,  p.  435. 

24 


370  DISEASES    OF    CHILDEEN. 

never  be  completely  developed  at  all ;  but  the  disease  is  the  same, 
and  in  all  other  respects  runs  its  course  in  the  usual  way.  I  have 
occasionally  in  practice  met  with  a  case  where  one  child  in  a 
family  whooped,  and  the  others,  who  presumablj^  suffered  from 
the  same  cough,  did  not  whoop  ;  and  I  have  known  the  pulmonary 
symptoms  gradually  assume  the  most  serious  aspect,  while  the 
whoop  has  declined,  even  if  it  has  not  been  altogether  absent. 
This  is  partly  to  be  explained  by  the  temperament  and  constitu- 
tion of  the  child.  The  dread  of  coughing,  or  the  fear  of  Ij'ing 
down  to  sleep,  or  a  fit  of  passion  or  crying,  is  quite  sufficient  to 
bring  on  a  paroxysm.  The  cough  consists  in  a  number  of  expira- 
tions, and  when  the  child  has  seemingly  forced  all  the  air  out  of 
the  lungs  (and  a  considerable  quantity  is  expelled)  the  efibrt  is 
succeeded  by  a  long  and  deep  inspiration.  As  the  air  passes  through 
the  glottis  the  peculiar  sound  or  whoop  is  produced,  and  this 
sound  is  liable  to  great  modification.  In  a  little  girl  under  my 
care  in  1874,  the  inspiration  was  very  clear  and  lengthened,  fading 
away  gradually  like  the  sharp,  shrill  note  of  a  flute.  In  other 
cases  it  is  more  barking  and  crowing.  If  bronchitis  is  not  present 
in  the  convulsive  or  spasmodic  stage,  we  may  detect  no  physical 
changes  in  the  lungs  beyond  a  slight  light  mucous  rale.  Between 
the  fits  of  coughing  the  vesicular  murmur  may  not  be  impaired, 
and  air  may  enter  the  minute  structure  of  the  lungs,  as  in  health  ; 
but  during  the  fit  of  coughing  the  lungs  empty  themselves  of  air, 
and  none  whatever  can  be  heard  to  enter  the  pulmonary  tissue. 
When  the  expirations  are  long  and  continuous  the  child  is  brought 
to  the  verge  of  suftbcation. 

A  good  deal  has  been  recently  written  on  the  connection  of  ulcers 
of  the  fr?enum  lingua  with  whooping-cough.  I  have  examined  a 
large  number  of  cases,  and  I  am  inclined  to  agree  with  those  ob- 
servers who  regard  them  as  accidental  rather  than  pathological. 
"When  present,  they  prove  the  violence  of  the  convulsive  j^arox- 
ysms.  As  the  tongue  is  protruded  from  the  mouth,  its  under  sur- 
face and  the  frsenum  lingure  come  in  contact  with  the  lower  incisor 
teeth,  so  that  these  ulcers  may  be  looked  upon  as  the  result  of 
injury.  They  are  absent  in  mild  cases,  or  where  the  duration  of 
rihe  disease  is  short,  or  the  low^er  incisor  teeth  are  not  developed. 

The  cough  of  some  children  when  sufi'ering  merely  from  a  com- 
mon cold  is  convulsive  and  ringing  ;  in  some  it  has  a  deep  and 
sonorous  sound,  which  parents  attribute  to  a  consumptive  origin  ; 


PERTUSSIS   OR   "WIIOOPIXG-GOUGH.  371 

and  in  others  it  has  a  croiipy  character,  which  they  tliink  is  the 
forerunner  of  croup ;  but  the  whoop,  when  present,  is  not  to  be 
mistaken,  and  settles  all  doubts  as  to  the  true  nature  of  the- 
disorder. 

When  whooping-cough  has  succeeded  to  the  eruptive  diseases, 
or  has  followed  any  acute  illness  or  long-standing  debility,  it  is 
difficult  to  treat  and  dangerous  in  its  results.  When  a  child  has 
no  sooner  recovered  from  measles  than  he  is  attacked  by  whooping- 
cough,  the  two  diseases  greatly  aggravate  the  danger.  Scarcely 
has  there  been  time  for  the  constitution  to  recover  its  lost  tone 
before  it  is  attacked  hj  a  second  disease,  and  so  what  at  first  might 
have  passed  off  as  simple  functional  disturbance,  now  becomes  in- 
tensified, and  ma}''  terminate  in  organic  change. 

Nervous  symptoms  are  more  readily  excited  in  some  children 
than  in  others,  and  these  cases  are  alwaj'S  anxious  ones — in  fact, 
nervous  irritation  exerts  a  powerful  influence  in  many  other  dis- 
eases of  childhood.  Dr.  Barnes,  speaking  of  the  influence  which 
peripheral  irritation  has  upon  the  nervous  centres  of  a  naturally 
irritable  child,  mentions  a  case  of  tetanus  induced  in  an  infant  by 
whooping-cough  which  came  under  his  own  observation.  He 
says,  "On  January  16th,  1866, 1  met  Mr.  Giles,  now  of  Henley-on- 
Thames,  on  the  case  of  a  boy  aged  nine  months.  He  had  been 
weaned  two  months,  and  was  taking  cows'  milk  and  Robb's  bis- 
cuits. He  had  had  whooping-cough  three  weeks,  having  taken  it 
from  his  brother.  During  the  last  three  days  a  singular  train  of 
nervous  symptoms  appeared;  first  trismus,  then  emprosthotonos, 
the  hands  touching  the  feet,  then  the  body  arched  back  into  opis- 
thotonos. The  fits  seemed  the  first  expression  of  the  impulse  to 
cough,  the  cough  coming  on  soon  after  the  fit.  Anything  in  a 
spoon  excited  cough  or  fit.  The  child  was  not  much  wasted,  but 
there  was  some  degree  of  antemia ;  the  bowels  had  been  out  of 
order,  the  stools  pale.  Calomel  and  rhubarb  had  corrected  this 
condition.  He  had  had  belladonna.  We  recommended  goats' 
milk,  solution  of  perchloride  of  iron,  and  gave  a  favorable  prog- 
nosis." The  child  recovered.  "  Such  a  case,"  adds  Dr.  Barnes, 
"  must  be  studied  in  connection  with  the  trismus  nascentium.  It 
proves  very  clearly  the  intimacy  of  the  association  between  whoop- 
ing-cough and  convulsive  diseases."*     This  is  a  truthful  maxim 

*  Lumleian  Lectures;  On  Convulsive  Diseases  of  Women,  Brit.  Med.  Journ.,  April 
19th,  1873,  p.  424. 


372  DISEASES    OF    CHILDREX. 

which  should  fix  itself  on  the  miuds  of  all  medical  men.  Irritation 
need  only  be  very  slight  and  transient  at  the  period  of  the  first 
dentition  to  originate  mischief  in  one  or  other  of  the  nervous  cen- 
tres. Convulsive  movements,  stopping  short  of  actual  culmination, 
are  exceedingly  common  at  this  early  period  of  life.  The  nervous 
system  is  so  highly  organized  that  any  impression  on  any  tissue  or 
organ  of  the  body  is  at  once  felt,  and  irritation,  however  varied 
and  remote,  freely  communicates  its  influence  to  it. 

Unless  complications  arise,  such  as  bronchitis,  pneumonia,  cere- 
bral or  mesenteric  disease,  whooping-cough  is  not  dangerous.  Al- 
though the  disease  I'naj  pursue  a  tedious  course,  and  cannot  be 
abruptly  terminated  by  any  method  of  treatment  with  which  we 
are  acquainted,  it  will  sooner  or  later  end  in  complete  recovery,  if 
these  complications  can  be  warded  ofl:'. 

Generally  the  amount  of  spasmodic  cough  bears  no  relation  to 
the  severity  of  the  bronchitis  when  it  is  present.  In  the  case  of  a 
strumous-looking  child,  five  years  of  age,  admitted  into  the  Samar- 
itan Hospital,  under  my  care,  in  December,  1874,  the  whooping 
was  very  moderate,  whilst  the  bronchial  affection  and  congestion 
of  the  lungs  were  very  severe,  the  pulse  reaching  140,  and  the  res- 
pirations 56  per  minute ;  the  pupils  were  dilated,  and  the  eyelids 
oedematous.  The  temperature,  which  was  102.6''  on  admission, 
fell  to  normal  in  five  days  ;  yet  the  gravity  of  the  case  did  not 
lessen  by  the  fall.  The  child  lay  betwixt  life  and  death  for  many 
days,  and  the  restlessness  became  extreme  at  night;  the  cough 
was  excessive,  and  attended  with,  coj^ious  bronchial  sputa ;  loud 
mucous  rales  were  heard  in  the  lungs.  The  violence  of  the  cough 
led  to  a  considerable  degree  of  emphysema  of  the  lungs,  and  when 
the  child  had  recovered,  the  chest  was  unduly  resonant  on  percus- 
sion. Rupture  of  the  air-cells  may  lead  to  an  emphysematous  con- 
dition of  the  face,  neck,  and  chest.  In  two  cases  under  my  care, 
a  prominent  and  doughy  swelling  was  situated  above  the  clavicles 
some  months  after  the  disease  w^as  cured.  , 

The  bronchial  glands  not  unfrequently  become  enlarged  in 
whooping-cough,  as  they  sometimes  do  in  the  course  of  scarlatina 
and  measles.  It  is  supposed  by  Dr.  Gueneau  de  Mussy,  that  by 
the  pressure  of  these  glands  on  the  pneumogastric  nerve,  and  par- 
ticularly on  the  inferior  laryngeal  branch,  the  peculiar  spasmodic 
cough  is  due.*     But  it  is  important  to  remember,  as  Dr.  Barlow 

*  Enlargement  of  the  Bronchial  Lymphatic  Glands  with  relation  to  Whooping- 
cough,  Brit.  Med.  Jour.,  1879,  vol.  ii,  p.  049. 


PERTUSSIS   OR   WHOOPIXG-COUGH.  373 

very  truly  states,  that  enlargement  of  the  bronchial  glands  in 
whooping  cough  is  not  constant,  and  that  they  may  be  enlarged 
without  paroxysmal  cough.* 

3.  The  terminal  or  last  stage  may  be  described  as  the  decline  of 
the  complaint.  The  cough  is  no  longer  so  paroxysmal,  the  sputa 
are  thicker  and  more  easily  expectorated,  and  there  is  no  vomit- 
ing. The  child  sleeps  souudlj'  at  night,  as  convalescence  is  ap- 
proached, and  gradually  gains  flesh  and  strength. 

Treatment. — Here  we  have  to  contend  with  difficulties.  Any 
contribution  that  could  throw  new  light  on  a  speedy  and  successful 
method  of  treating  whooping-cougli  would  be  hailed  with  very 
great  satisfaction.  Few  diseases  are  more  rebellious  to  treatment, 
whether  in  the  acute  or  chronic  stage,  and  nothing  would  be  more 
presumptuous  than  to  lay  down  anj'  plan  for  general  adoption. 
-Whooping-cough,  like  many  other  diseases,  must  be  treated  on 
general  principles,  for  we  know  of  no  real  specific.  That  plan  will 
be  most  successful  which  meets  the  peculiarities  of  each  case,  no 
two  cases  being  exactly  alike,  and  the  epidemic  being  seldom  of 
the  same  character  and  severity.  The  weakly,  strumous  child, 
whose  disease  is  complicated  with  a  pulmonary  or  a  cerebral  affec- 
tion, must  not  be  subjected  to  the  same  treatment  as  a  strong  and 
healthy  child,  for  whooping-cough  is  modified  by  the  strength  and 
constitution  of  the  child,  by  the  age,  and  by  the  season  of  the  j'ear. 
When  catarrhal  or  inflammatory  symptoms  prevail,  or  general 
bronchitis  is  present,  our  plan  of  treatment  is  obvious.  If  convul- 
sions or  threatening  symptoms  of  hydrocephalus  should  supervene 
it  is  equally  plain ;  but  to  mitigate  suffocative  attacks  of  spasm, 
and  to  cut  short  this  painful  disease,  we  have  no  remedy  on  which 
we  can  confidently  rely. 

In  cases  where  bronchitis  is  a  prominent  feature,  and  febrile 
symptoms  are  present,  cooling  aperients  and  saline  medicines  are 
called  for.  A  mixture  containing  nitrate  of  potash,  tincture  of 
hyoscyamus,  ipecacuanha  wine,  and  the  solution  of  acetate  of 
ammonia  will  be  useful.  If  the  febrile  symptoms  are  severe,  and 
the  bowels  disposed  to  be  obstinate,  a  few  grains  of  sulphate  of 
magnesia  may  be  added  to  each  dose,  which  will  have  an  aperient 
effect  and  moderate  the  fever.  Sometimes  it  is  necessary  to  give  a 
good  purge,  and  after  it  the  child  is  lighter  and  better.     A  grain 

*  Enlargement  of  Bronchial  Glands  with  relation  to  Whooping-cough,  ihid.,  p. 
8S9. 


374  DLSEA5E.S    OF    CHILDEEX. 

of  calomel,  and  a  few  grains  of  scammonj  or  rhubarb,  will  now 
and  then  do  great  good  by  emptying  tlie  bowels,  subduing  the 
fever,  and  relieving  the  laryngeal  spasm.  At  an  early  stage,  if  the 
child  is  strong  enough,  we  may  follow  out  this  plan  with  advan- 
tacre,  and  cases  occur  where  it  succeeds  when  specific  treatment 
fails.  In  this  condition  we  sometimes  find  the  lungs  full  of  loose, 
scattered  bronchial  rules,  and  the  child  so  prostrate  that  it  cannot 
stand,  the  skin  hot,  the  tongue  furred,  the  respiration  short,  quick, 
and  catching.  The  spasmodic  cough  and  constant  expectoration 
reduce  the  child's  strength  much  quicker  than  in  uncomplicated 
bronchitis.  The  child  is  now  apt  to  become  heavy  and  torpid, 
and  after  a  fit  of  coughing  and  sickness  to  fall  into  a  drowsy  state 
from  congestion  of  the  brain.  When  the  lips  swell,  the  eyes  are 
heavy  and  meaningless,  and  the  face  becomes  bloated  from  violent 
coughing  and  bronchial  congestion ;  it  may  be  necessary  to  apply 
two  or  three  leeches  to  the  head,  and  give  a  grain  of  calomel,  fol- 
lowed by  a  soap-and-water  enema,  if  the  bowels  do  not  quickly 
respond. 

As  the  febrile  disturbance  diminishes,  the  nervous  prostration 
and  harassing  cough  are  sometimes  very  troublesome.  In  this 
condition  carbonate  of  ammonia  and  spirits  of  chloroform  are  neces- 
sary to  aid  the  expectoration  (Form.  61);  but  so  long  as  there  is 
much  irritation  in  the  lungs  we  must  be  careful  in  the  use  of  seda- 
tives, as  I  have  previously  mentioned.  In  some  cases  the  child 
becomes  much  exhausted  from  the  violence  of  the  cough  and  the 
copiousness  of  the  expectoration ;  the  skin  becomes  relaxed  and 
sweating,  a  state  of  passive  congestion  of  the  whole  surface  ensues, 
and  stupor  and  drowsiness  set  in.  Here  the  exhibition  of  seda- 
tives would  be  dangerous  from  more  points  than  one,  and  in  place 
of  them  we  must  give  ammonia  and  bark,  and  supply  the  child 
with  nutritious  food  in  small  and  repeated  quantities. 

When  we  have  succeeded  in  overcoming  the  inflammatory  state, 
antispasmodic  remedies  are  valuable,  the  diet  being  carefully  regu- 
lated, and  the  action  of  the  bowels  being  kept  as  free  as  is  consis- 
tent with  the  strength  of  the  patient.  On  listening  to  the  chest 
we  may  often  detect  extensive  mucous  rales  and  a  large  accumu- 
lation of  phlegm  in  the  air-passages,  and  there  is  necessaril}'  danger 
lest  through  declining  strength  the  phlegm  should  fail  to  excite 
cough  in  the  bronchial  mucous  membrane.  At  first  it  may  excite 
greater  cough,  but  as  the  child  becomes  exhausted  by  these  painful 


PERTUSSIS   OR   WHOOPIXG-COUGH.  375 

efforts  tlie  cough  fails  to  come  on.  The  right  side  of  the  heart 
becomes  overloaded  from  obstruction  to  the  capillary  circulation, 
and  a  state  of  passive  or  venous  congestion  ensues,  attended  with 
prostration  and  collapse.  I  have  seen  a  few  cases  terminate  fatally 
in  this  way,  death  being  preceded  by  cerebral  congestion  and  stu- 
por, cold  clammy  skin,  and  blueness  of  the  general  surface.  Some- 
times the  inflammation  spreads  to  the  smaller  bronchi,  or  to  the 
air-cells  of  the  lung  itself,  leading  to  condensation  of  the  lung, 
even  if  it  does  not  produce  tubercular  disease  in  feeble  and  badly 
nourished  children. 

"When  the  strength  is  fairly  good,  and  the  patients  are  harassed 
by  perpetual  cough  and  glairy  tenacious  mucus,  we  may  order  a 
teaspoonful  of  ipecacuanha  wine  every  ten  minutes  at  bedtime  till 
vomiting  ensues ;  but  the  treatment  requires  judgment,  lest  we 
weaken  the  digestive  powers  and  lay  the  foundation  for  convul- 
sions or  some  other  serious  complication.  Usually  one  dose  is 
enough,  and  the  patient  falls  into  sound  sleep  after  it.  I  have 
seen  the  greatest  adv'antage  follow  this  plan  of  treatment  in  a 
large  number  of  cases,  when  a  bromide  mixture  with  belladonna 
has  been  given  three  times  a  day,  and  an  emetic  at  night.  This 
plan  of  making  the  child  sick  is  of  less  use  if  the  minute  bronchi 
are  choked  up,  and  there  are  any  signs  of  impeded  circulation 
through  the  heart  and  lungs,  but  it  is  of  especial  value  where  the 
upper  bronchial  tubes  are  loaded,  and  the  larynx  is  congested  and 
irritated.  Gentle  emetics  will  aid  the  expulsion  of  morbid  secre- 
tions, subdue  the  cough,  moderate  the  fever,  and  rouse  the  child 
from  stupor  and  lethargy.  If  the  child  has  been  overdosed  with 
narcotics,  this  treatment  will  be  the  more  serviceable.* 

Diet  is  of  the  first  importance  in  the  treatment  of  whooping- 
cough.  It  should  be  light  and  nutritious.  Egg  pudding,  beef 
tea,  and  milk  are  the  chief  kinds  of  food  to  be  chosen,  because 
they  are  digestible  and  non-irritating.  Bread  may  be  given 
soaked  in  milk  ;  but  a  small  piece  of  plain  bread  and  butter  will 
often  provoke  a  fit  of  coughing.  ]\Iinced  mutton  and  chicken,, 
in  very  small  quantities,  are  suitable  for  children  of  a  certain  age. 
Barley-water,  sweetened,  and  flavored  with  lemon,  is  an  excellent 
mucilaginous  drink.  The  stomach  is  very  sensitive,  and  the  ner- 
vous system  so  impressible  in  this  disease,  that  improper  food, 
cold  air,  or  deficient  clothing,  will  be  sure  to  aggravate  the  com- 

*  See  the  action  of  emetics  in  Chaps.  II  and  XXXVI. 


376  DISEASES   OF   CHILDREX. 

plaint.  A  child  should  always  be  fed  immediately  after  an  attack 
of  cough  accompanied  b}^  vomiting,' so  that  the  food  may  be  di- 
gested and  assimilated  ere  the  next  paroxysm  comes  on.  If  this 
be  not  attended  to,  the  food  is  apt  to  be  vomited  in  the  next 
attack  in  a  partially  digested  condition,  and  so  is  lost  for  all  pur- 
poses of  nutrition.  As  far  as  possible,  the  most  perfect  rest  of 
body  and  mind  should  be  maintained. 

The  late  Dr.  Fuller  tried  sulphate  of  zinc,  in  gradually  increas- 
ing doses,  to  subdue  the  spasmodic  cough.  "  In  five  only  of  fifty- 
nine  cases  in  which  I  had  the  opportunity  of  testing  its  virtues 
did  it  fail  in  giving  marked  and  speedy  relief."*  In  no  instance 
did  the  disease  last  longer  than  the  eighth  week. 

In  1858  Dr.  Fuller  obtained  the  most  satisfactory  results  from  a 
combination  of  sulphate  of  zinc  with  belladonna.  He  estimated 
the  average  duration  of  an  uncomplicated  attack  to  be  three 
weeks  or  a  month.  "As  soon  as  the  whoop  declares  itself,  a 
draught  is  given  ever}^  three  or  four  hours,  containing  a  grain  of 
sulphate  of  zinc  and  a  sixth  of  a  graip  of  extract  of  belladonna, 
to  two  drachms  of  syrup  of  orange,  in  from  two  to  six  of  water ; 
and  an  additional  grain  of  sulphate  of  zinc,  and  an  additional 
sixth  of  a  grain  of  belladonna,  are  added  to  each  dose  daily,  or 
every  alternate  day,  until  the  quantity  taken  daily  amounts  to  from 
six  grains  to  a  drachm  of  zinc,  and  from  two  to  six  grains  of  the  ex- 
tract of  belladonna,  according  to  the  age  of  the  patient.  To  children 
under  a  twelvemonth  old,  I  have  never  administered  more  than 
ten  grains  of  the  zinc  and  two  grains  of  the  belladonna  daily, 
which  were  given  in  doses  of  a  grain  and  a  quarter  of  the  zinc, 
and  a  quarter  of  a  grain  of  belladonna,  ever}^  three  hours  ;  whilst 
for  children  of  eight  or  ten  years  of  age  I  frequently  prescribe 
half  a  drachm,  or  two  scruples  of  the  zinc  and  six  grains  of  bella- 
donna." f  Belladonna  deserves  to  rank  among  the  first  of  our 
remedies  in  the  treatment  of  this  affection.  The  excitement  and 
frequency  of  the  cough  are  allayed  by  it  in  a  marvellous  manner. 
Large  doses  of  belladonna  are  well  borne  by  children.  But  it  is 
important  to  increase  the  dose  slowly,  and  if  excitement,  feverish- 
ness,  or  bronchial  engorgement  should  ensue,  then  salines  and 
emetics  may  be  called  for. 

I  have  met  with  few  instances  where  belladonna  has  not  proved 

*  On  Diseases  of  the  Lungs,  1867,  p.  384. 
t  Ibid.,  p.  3S6. 


PERTUSSIS   OR   WHOOPING-COUGH.  377 

of  benefit,  and  none  -where  it  has  appeared  to  do  harm.  It  is  of 
most  use  in  the  spasmodic  stage,  when  the  bronchial  irritation  has 
subsided.  I  usually  l)egin  with  a  quarter  of  a  grain  for  a  child 
aged  two  years,  in  glycerin  or  syrup  of  tolu,  every  four  hours.  If 
it  has  no  effect  I  give  the  same  dose  every  two  hours  until  it  has 
made  an  impression  upon  the  system.  In  a  recent  case  I  found 
that  the  spasmodic  cough  was  uncontrolled  till  the  child,  aged 
eight  years,  took  one  grain  every  three  hours.  After  a  few  doses 
the  pupils  became  dilated,  the  cough  lessened,  and  the  child 
obtained  refreshing  sleep.  Dr.  Barnes  observes:  "The  value  of 
belladonna  in  allaying  spasmodic  or  convulsive  action  is  often 
striking.  I  have  seen  nothing  so  effective  in  the  whooping-cough 
of  children.  Its  power  over  other  forms  of  convulsion  is  incon- 
testable."* But,  as  I  have  pointed  out,  if  it  is  to  be  of  service,  we 
must  give  it  in  gradually  increasing  doses  till  its  sedative  effects 
become  manifest  and  the  pupils  are  fully  dilated.  Like  some 
•  other  remedies  employed  in  this  intractable  affection,  it  has 
obtained  no  credit,  and  been  looked  upon  as  inert  and  valueless. 
This  is  because  the  dose  o-iven  is  too  small.  I  can  have  no  doubt 
of  the  value  of  the  drug,  and  at  one  stage  or  another  I  almost 
invariably  give  it.  It  lessens  the  frequency  and  severity  of  the 
spasmodic  attacks  in  a  remarkably  certain  manner,  and  subdues 
the  tendency  to  convulsive  movements.  When  its  action  has  been 
kept  up,  and  especially  when  combined  with  bromide  of  potassium, 
it  tranquillizes  the  nervous  system,  induces  sleep,  and  relieves  the 
cough. 

Sulphate  of  atropia  may  be  given  in  place  of  belladonna,  from 
being  tasteless,  and  the  readiness  with  which  it  dissolves  in  water. 
The  dose  at  first  should  not  exceed  the  one-hundredth  part  of  a 
grain.  "  One-sixtieth  of  a  grain  of  atropia  or  its  salt,  given  hypo- 
dermically,  will  generally  produce  slight  dryness  of  the  throat  or 
other  indications  of  its  constitutional  action.  Where  rapidity  of 
action  is  required,  this  is  the  best  method  of  administering  bella- 
donna."t 

Cannabis  indica  is  recommended  by  some  practitioners  in  the 
spasmodic  stage.  One  drop  of  the  tincture  in  a  teaspoonful  of 
w^ater,  may  be  given  three  or  four  times  a  day  for  each  year  of  the 
child's  age. 

*  Dr.  Barnes,  Liimleian  Lectures,  On  the  Convulsive  Diseases  of  Women.,  Brit. 
Med.  Journ.,  May  3d,  1873,  p.  483. 
\  t  }1.  C.  Wood,  M.D.,  op.  cit.,  1876,  p.  257. 


378  DISEASES    OF    CHILDEEN. 

Hydrate  of  chloral  has  done  good  in  the  spasmodic  stage,  and 
relieved  the  cough,  even  when  ipecacuanha  and  belladonna  have 
failed.  Five  grains  every  four  hours  may  be  given  to  a  child  five 
years  of  age.*  Of  twenty-two  cases  in  which  it  was  employed 
"  to  relieve  the  cough,  after  the  whooping  stage  was  fairly 
reached,"  in  only  three  did  it  produce  any  "  appreciable  benefit. "f 

Croton-chloral  has  been  spoken  of  as  a  specific.:]: 

Bromide  of  potassium,  like  belladonna,  is  of  most  value  in  the 
spasmodic  stage  ;  and  if  convulsions  or  much  nervous  irritability 
should  complicate  the  condition,  it  will  be  all  the  more  serviceable. 
When  there  is  much  bronchial  congestion  and  secretion  it  should 
be  held  in  reserve,  and  not  given  till  the  lungs  are  freed  of  this 
load  of  phlegm  by  an  emetic ;  but  a  moderate  amount  of  catarrh 
and  bronchitis  do  not  contraindicate  its  use. 

In  whooping-cough  when  the  breathing  is  excited,  bromide  of 
potassium  as  a  sedative  to  the  respiratory  centre  is  indicated. 
On  the  other  hand,  when  the  respiration  is  labored  or  shallow, 
then  belladonna  is  the  drug  to  use  as  a  stimulant  to  the  respira- 
tory centre. 

Dr.  Dillnberger  says,  "  Some  paroxysms  of  coughing  may  be 
allayed  by  laying  a  cold  dressing  on  the  lower  part  of  the  breast- 
bone, and  hence,  too,  water  poured  over  the  breast-bone  is  recom- 
mended."§  This  treatment  is  new  to  me ;  but  we  can  readily 
understand  that  it  may  exert  a  tonic  and  remedial  efiect  where 
there  is  an  absence  of  bronchial  congestion,  and  the  spasmodic 
cough  is  the  chief  and  distressing  symptom.  The  spasmodic 
paroxysms  are  sometimes  very  alarming,  and,  in  a  case  I  saw  in 
1876,  I  thought  that  the  child  would  have  been  sufibcated  from 
their  violence  and  frequency. 

When  a  paroxysm  of  whooping-cough  is  about  to  commence, 
the  head  should  be  elevated,  and  the  child  raised  up  if  in  bed. 
Everj'thing  about  the  neck  and  breast  should  be  loosened.  If  the 
child  is  old  enough  to  understand  what  is  said  to  him,  he  should 
be  encouraged  and  reassured.     The  temperature  of  the  room  in 

*  Hydrate  of  Chloral  in  Pertussis,  Clinical  Lectures  on  Medicine  by  Dr.  Murcliison, 
Lancet,  Oct.  29th,  1870. 

t  Chloral  Hydrate,  by  W.  Bathurst  Woodman,  M.D.,  St.  And.  Med.  Grad.  Trans., 
1871,  vol.  iv,  p.  222. 

t  The  Lancet,  1877,  p.  223. 

?  Handybook  of  the  Treatment  of  Women's  and  Children's  Diseases,  p.  176.  London, 
J.  and  A.  "Cliiircliill,  1871. 


PERTUSSIS   OR   WHOOPING-COUGH.  379 

the  early  stages  requires  to  be  warm  and  elevated,  as  in  cases  of 
bronchitis.  The  tenacious  mncus  must  be  wiped  from  the  child's 
mouth  with  a  handkerchief;  the  distress  and  alarm  caused  by 
the  little  patient's  attempt  to  dislodge  it  is  characteristic,  and, 
from  the  fear  induced,  the  paroxysm  is  often  prolonged,  and  the 
child  much  exhausted. 

Alum  has  been  considered  of  benefit  by  some  authorities  in  the 
spasmodic  stage  of  uncomplicated  whooping-cough  ;  but  I  have 
been  so  satisfied  with  belladonna  that  I  have  seldom  employed  it. 
When  all  fever  has  departed,  or  the  complaint  has  become  chronic 
and  irksome,  it  may  be  given  with  syrup  three  or  four  times  a 
day,  in  doses  of  three  or  four  grains.  When  the  bronchial  mucous 
membrane  furnishes  a  copious  secretion  (bronchorrhoea),  and  the 
child  is  si:ettino;  weak  from  the  couo-h  and  sickness,  alum  seems  to 
act  both  as  an  astringent  and  tonic,  lessening  the  frequency  and 
severity  of  the  paroxysms  without  causing  constipation  or  any  ill 
consequences.  Combined  M'ith  belladonna,  Meigs  and  Pepper 
have  obtained  better  results  than  with  any  other  remedy.  They 
prescribe  the  undermentioned  formula.* 

I  have  never  tried  nitric  acid  in  the  doses  recommended  by  the 
late  Dr.  Gibb,  but  I  have  frequently  given,  in  the  decline  of  the 
complaint,  the  nitromuriatic  acid  alone,  or  with  tincture  of  bark, 
to  improve  digestion  and  appetite.  Much  in  the  same  way,  and  in 
the  same  states,  we  should  prescribe  iron. 

I  have  rarely  given  hydrocj^anic  acid  alone.  Its  specific  action 
is  best  seen  in  controlling  the  severity  of  the  paroxysms,  and  the 
frequency  of  the  convulsive  cough.  .Its  sedative  action  on  the  gas- 
tric nerves  may  also  have  a  beneficial  effect  in  allaying  the  irrita- 
tion of  the  digestive  organs,  and  diminisMng  the  general  sensibility 
of  the  nervous  system  ;  but  it  will  have  little  or  no  effect  on  the 
cough,  if  the  irritation  depends  on  the  accumulation  of  phlegm  in 
the  air-passages.  Here  it  may  be  necessary  to  give  an  emetic  in 
the  daytime  as  well  as  at  night.  To  be  of  service  hydrocyanic 
acid  should  be  given  frequently,  according  to  the  severity  of  the 

*  Formula  57 : 

R.  Ext.  belladonnse, gr.  j 

Aluminis,       .         .         . ^ss. 

Syr.  zingib. 
Syr.  acacise, 

Aquara  ad 5J. — M. 

3j  four  times  in  the  twenty-four  hours.     For  a  cliild  a  year  old. 


380  DISEASES    OF    CHILDREX. 

Spasm  and  the  frequeucj  of  the  cough.  It  is  a  reraedj  that  re- 
quires careful  watching,  for  an  overdose  maj"  produce  syncope  or 
convulsions,  and  it  is  for  this  reason  that  I  seldom  prescribe  it. 

When  the  whoop  is  declining,  and  the  febrile  symptoms  are  de- 
parting, hydrocyanic  acid  and  quinine  are  good  remedies,  and  may 
be  o-iven  with  advantag-e,  even  when  there  is  some  rhonchus  in  the 
lungs,  and  a  little  moist  crepitation.  In  three  children  in  one 
family,  who  were  all  seized  with  whooping  cough  about  the  same 
time,  I  found  that  in  each  case  the  frequent  and  spasmodic  cough 
was  rapidly  relieved  by  this  treatment,  and  they  were  able  to  di- 
gest sufficient  nourishing  food  to  strengthen  the  general  system 
and  shorten  the  duration  of  the  disease.  At  the  end  of  a  week 
or  fortnight,  the  signs  of  pulmonary  irritation  may  all  disappear, 
and  cod-liver  oil  and  preparations  of  iron  will  then  complete  the 
cure. 

But  among  medicines  used  in  whooping-cough  the  old-fashioned 
remedy  of  carbonate  of  potash  cannot  be  ignored.  The  testimony 
that  has  been  urged  in  its  favor  is  very  strong.  It  is  of  most 
service  when  the  secretions  in  the  larynx  are  tenacious,  and  ad- 
here to  the  parts  about  the  glottis,  so  that  they  cannot  easily  be 
dislodged  by  expectoration.  The  alkali  is  of  service  here,  as  it  is 
in  the  early  stages  of  bronchitis,  when  the  bronchial  membrane  is 
vascular,  secreting,  and  irritable.  It  controls  the  violence  of  the 
paroxysms  which  so  terribly  exhaust  the  child,  and  it  enables  the 
copious  secretion  about  the  air-passages  to  be  more  easily  dislodged. 
The  cochineal  usually  combined  with  the  potash  mixture  is  proba- 
bly of  no  value,  but  it  is  pleasant  to  the  eye,  and  with  syrup  will 
not  be  refused  by  the  youngest  child.* 

As  to  the  topical  application  of  remedies  to  the  larynx  in  this 
intractable  disorder,  I  have  had  no  experience.  Sponging  the 
pharynx  with  a  solution  of  nitrate  of  silver  was  long  ago  advo- 
cated by  Dr.  Eben  Watson,  of  Glasgow,  Dr.  Horace  Green,  of  Xew 
York,  M.  Joubert,  and  some  other  French  physicians.  Dr.  Watson 
applied  it  successfully  to  a  baby  at  the  breast,  whose  life  was  in 
danger,  and  he  has  given  some  statistics  to  show  that  of  sixty-six 

*  Formula  58 : 

K.  Cocci, gr.  V 

Potass,  bicarb., gf-  xl 

Synipi, .^sa. 

Aquam  ad .^iv. — M. 

A  dessertsiioonfiil  every  three  or  four  liours.     For  a  cliild  two  years  old. 


PERTUSSIS   OR   WnOOPING-COrGH.  S81 

cases  treated  by  him,  forty-six  were  cured  in  a  fortnight,  and  the 
remaining  twenty  in  three  or  four  weeks.  Xot  one  child  resisted 
the  treatment,  In  another  calcuhition,  from  a  severe  epidemic  at 
Glasgow,  he  gives  the  proportions  of  deaths  at  only  0.6  per  cent., 
and  t]]e  cases  cured  within  a  month  were  36.5  per  cent.*  There 
would  seem  to  be  something  extraordinary  in  the  rapidity  of  these 
cures,  because,  looking  at  the  experience  of  most  writers  on  the 
subject,  the  duration  of  the  disease  has  generally  been  much  longer. 
A  disease  that  m  ty  end  in  a  fortnight,  or  extend  over  six  months, 
pursues  such  an  indefinite  course  that  no  reliable  calculation  can 
be  made.  If  the  application  of  a  solution  of  nitrate  of  silver  (3j 
to  the  oj)  is  such  a  valuable  remedy  we  are  somewhat  surprised  to 
learn  that  it  is  not  more  generally  adopted.  It  appears  to  me  that 
sponging  the  phar3mx  and  aperture  of  the  glottis  may  give  relief, 
in  the  purely  spasmodic  stage,  to  children  of  six  or  seven  years  of 
age  ;  but  to  pass  the  sponge  beneath  the  glottis  into  the  larynx, 
which  is  the  only  way  to  act  on  the  secretion  which  sets  up  the 
spasm,  must  be  attended  with  difficulty  and  danger.  The  larynx 
is  very  small  in  young  children,  and  it  would  require  considerable 
skill  to  enter  it.  Then,  too,  the  alarm  and  agitation  produced  by 
the  operation,  are  quite  enough  to  increase  the  spasm,  if  not  to 
provoke  a  convulsion. 

Dr.  R.  J.  Leef  has  called  attention  to  the  use  of  carbolic  acid  in 
the  treatment  of  whooping-cough.  One  part  of  carbolic  acid  and 
ten  parts  of  water  form  a  standard  mixture,  of  which  two  drachms 
are  to  be  mixed  with  four  ounces  of  water.  This  is  put  into  a 
steam-draught  inhaler,  and  the  vapor  inspired  every  ten  minutes 
or  quarter  of  an  hour,  three  or  four  times  a  day.  Dr.  Lee  con- 
tends that  carbolic  acid  used  in  this  manner  is  a  more  satisfactory 
remedy  than  any  other,  and  that  it  has  proved  of  advantage  in  other 
diseases  of  the  respiratory  organs.  Dr.  Burchardt,:|:  Lecturer  at 
the  University  of  Berlin,  states  that  in  1873  he  used  a  solution  of 
carbolic  acid  in  water  for  inhalation  three  times  a  day  (one  and  a 
half  to  two  parts  of  acid  in  a  hundred  parts  of  water)  with  perfect 


*  On  the  Topical  Medication  of  the  Larynx,  by  Dr.  Eben  "Watson,  chap,  vi,  p.  103. 
London,  .J.  Churchill,  1854. 

t  British  Medical  Association,  held  in  Edinburgh,  August  3d,  4th,  5th,  and  6th,  1875. 
Section  A  :  Medicine.  Kemarks  on  Whooping-cough,  and  its  Treatment  with  Carbolic 
Acid  Vapor,  by  Robert  J.  Lee,  M.D.,  London. 

X  Treatment  of  Whooping-cough  with  Carbolic  Acid  Vapor,  Brit.  Med.  Journ., 
September  25th,  1875,  p.  396. 


382  DISEASES   OF   CHILDP.EX. 

success  in  the  treatment  of  wliooping-cougli  and  other  affections 
of  the  respiratory  organs.  Mr,  T.  D.  Harries  records  several  cases 
of  whooping-cough  which  resisted  every  remedy  but  carbolic  acid, 
under  which  the  malady  rapidly  subsided.  It  should  not  only  be 
used  internally,  but  be  deposited  about  the  house.*  Dr.  George 
E,ugo:,f  of  Chapham  Eoad,  appears  to  have  successfully  employed 
carbolic  inhalation  as  far  back  as  1866  in  the  cases  of  five  of  his 
own  children.  His  plan  is  both  ingenious  and  ready.  A  few 
minims  of  the  acid  are  inserted  into  the  bowl  of  a  tobacco-pipe, 
which  the  children  smoke.  Dr.  Eugg,  however,  is  doubtful  as  to 
the  efficacy  and  safety  of  the  remedy,  for  he  says,  "  the  use  of 
carbolic  acid  is  not  without  danger.^'  He  now  prescribes  a  solu- 
tion of  chlorinated  soda  with  permanganate  of  potash,  in  the  form 
of  spray,  both  for  inhalation  and  disinfection  ;  he  also  fumigates 
the  room  by  meaus  of  iodine.  As  bromide  of  potassium,  bella- 
donna, and  an  emetic  at  bedtime  are  also  given,  it  is  impossible  to 
say  what  share  of  credit,  if  any,  the  carbolic  acid  inhalation  is 
entitled  to.  It  seems  to  me  that  we  are  dealing  with  a  disease 
presenting  so  many  local  and  constitutional  variations — spasmodic, 
congestive,  and  inflammatory — that  no  specific  treatment  and  no 
medicated  inhalation  will  be  suitable  for  every  period  and  stage 
of  the  complaint. 

In  the  neurosal  stage,  quinine  and  bromide  of  potassium  are  very 
useful ;:}:  zinc  and  belladonna  are  also  sometimes  efficacious,  as  I 
have  before  remarked ;  but  if  the  lung's  are  loaded  with  mucus, 
this  must  be  got  rid  of  before  any  of  these  remedies  can  be  of 
service,  for  as  long  as  it  remains  in  the  bronchial  tubes  it  keeps 
up  the  cough,  and  exhausts  the  child.  We  must  never  forget  to 
keep  the  salient  points  before  us, — the  neurosal  side  is  the  essential 
factor  in  one  case,  the  pulmonarj^  or  brouchitic  in  the  other. 

Any  error  of  diet,  and  especially  overfeeding,  fatigue,  or  ex- 
posure to  cold,  will  bring  on  a  return  of  the  symptoms  when  the 

*  The  Lancet,  July  13th,  1878. 

■{•  Treatment  of  Whooping-cough  with  Carbolic  Acid  Inhalation,  Brit.  Med.  Journ., 
October  2d,  1875,  p.  425. 
X  Formula  59: 

R.  Tinct.  quinife 2[ij 

Potass,  bromid., gi"-  xl 

Giycerini, 5'^^- 

Aquam  ad 5^^'- — ^^• 

A  dessertspoonful  three  times  a  day,  for  a  child  five  years  old. 


ENLAEGED   BRONCHIAL   AND    MEDIASTINAL   GLANDS.  383 

whooping  "has  entirely  disappeared,  and  we  have  pronounced  the 
patient  cured.  The  peculiar  cough  may  recur  after  three  months' 
cessation  when  convalescence  has  been  interfered  with. 

In  the  cough  which  often  remains  after  pertussis,  as  a  form  of 
habit,  quinine  is  most  useful.  It  may  be  given  as  the  hydrobro- 
mate,  or  with  hydrobromic  acid,  with  advantage. 

Change  of  air  and  locality  are  very  serviceable,  and  will  some- 
times effectually  get  rid  of  the  remaining  cough  in  a  short  time. 
In  some  cases  change  appears  to  be  attended  by  no  advantage,  but 
it  should  always  be  advocated  as  soon  as  the  disease  becomes 
chronic,  and  has  proved  rebellious  to  treatment.  If  the  general 
health  keeps  fairly  good,  and  no  complications  arise,  a  nutritious 
and  careful  diet,  with  an  occasional  aperient,  is  all  that  is  de- 
manded till  the  malady  wears  itself  out. 


CHAPTER   XXXIII. 

ENLARGED  BRONCHIAL  AND  MEDIASTINAL  GLANDS. 

Causes:  Unfavorable  hygienic  conditions — Cold  and  exposure — The  exanthemata — Evil 
effects  of  overfeeding.  Symptoms  :  Bronchial  irritation  and  attacks  of  dyspnoea 
resembling  spasmodic  asthma — Cases  in  illustration  —  Fosi-mortem  appearances. 
Treatment  :  Expectorants  and  sedatives  to  relieve  cough  and  dyspnoea — Prepara- 
tions of  iron  and  cod-liver  oil — Application  of  a  weak  solution  of  tincture  of  iodine  to 
the  enlarged  glands. 

Closely  associated  with  the  morbid  changes  in  connection  with 
hypertrophy  of  the  mesenteric  glands  are  those  similar  changes 
observed  in  the  bronchial  and  mediastinal  glands.  The  constitu- 
tional condition  which  originates  the  complaint  in  both  sets  of 
cases  is  similar  ;  but  as  the  symptoms  are  necessarily  difierent  and 
often  obscure  in  the  latter,  I  shall  devote  a  separate  chapter  to 
the  consideration  of  them. 

Below  the  bifurcation  of  the  trachea,  in  the  angle  formed  by  the 
divergence  of  the  two  bronchi,  from  ten  to  fifteen  lymphatic  glands 
are  situated ;  and  glands  also  exist  along  the  course  of  the  bronchi, 
chiefly  behind  them. 

Dr.  Quain  states  the  important  fact,  that  in  health  these  glands 
are  proportionately  larger  in  infancy  than  in  the  adult.* 

*  Diseases  of  the  Bronchial  Glands,  Brit.  Med.  Journ.,  vol.  ii,  1878,  p.  863. 


384  DISEASES    OF   CHILDREX. 

Being  lymphatic  organs,  these  glands  are  subject  to  the  same 
diseases  that  attack  their  homologues  in  other  parts  of  the  body, 
as,  for  example,  that  simple  strumous  enlargement  so  common  in 
the  glands  in  the.  neighborhood  of  the  sterno-mastoid  muscles. 
But,  from  their  situation,  any  enlargement  of  the  bronchial  glands 
entails  the  risk  of  grave  mechanical  results.  Pressure  on  a  bron- 
chus, on  branches  of  the  great  vessels  of  the  lung,  or  on  the  pneu- 
mogastric  nerve,  cannot  fail  to  aflect  most  seriously  the  processes 
of  respiration  and  circulation.  -  As  glands  exist  in  the  mediastina, 
they  may  from  their  situation  cause,  when  diseased,  complica- 
tions almost  as  severe  as  when  the  lymphatics  of  the  bronchi  are 
involved. 

The  causes  of  lymphatic  enlargements  in  the  mediastinum  and 
around  the  bronchi  are  doubtless  similar  to  the  causes  of  swelling 
in  the  glands  elsewhere.  Thus,  unfavorable  hygienic  conditions, 
debilit}'  from  disease,  starvation,  or  neglect,  may  induce  the  dis- 
ease under  consideration.  Cold  and  exposure  are  common  ex- 
citing causes  of  congestion  of  these  glands,  or  disease  may  be 
provoked  by  the  glands  participating  in  the  inflammation  of  sur- 
rounding tissues  with  which  they  may  chance  to  be  connected. 
Luring  whooping-cough,  the  exanthemata,  and  typhoid  fever,  the 
bronchial  glands  are  apt  to  become  enlarged.  The  disease  may 
be  met  with  during  the  first  dentition  ;  it  is  intimately  connected 
with  struma  and  tubercle,  and  the  hj^pertrophied  glands  undergo 
caseous  degeneration,  or  even  abscess  and  suppuration.  Its  fre- 
quency in  early  life  is  admitted  by  nearly  all  authorities  on  the 
subject ;  yet  the  observations  of  Dr.  Quain  "  on  young  persons 
and  adults  show  that  in  fifty-nine  cases,  twenty-one  were  males 
and  thirty-six  females  (in  one  case  the  sex  was  not  recorded).  Of 
these,  two  were  under  ten  years  of  age,  nine  were  between  ten  and 
twent}'  years  of  age,  eighteen  were  between  twenty  and  thirty,  and 
twenty-six  were  over  thirty  years  of  age  ;  while  in  three  cases  the 
age  was  not  stated.  If  these  observations  justify  any  inference,  it 
is  that  females  are  more  liable  to  disease  of  the  bronchial  glands 
than  males,  and  that  the  disease  occurs  with  increasing  frequency 
after  puberty. ""^ 

Dr.  Goodhart  has  insisted  on  the  evil  effects  of  overfeeding  in 
association  with  enlargement  of  the  mediastinal  glands.   He  shows 

*  Diseases  of  the  Broncliial  Glands,  Erit.  Med.  Journ.,  1878,  vol.  ii,  p.  SG4. 


ENLARGED    BROXCHIAL    AXD    MEDIASTINAL    GLANDS.  385 

that  this  enforced  intemperance  with  regard  to  diet  not  only  pro- 
duces disease  of  the  alimentary  canal,  but  "  does  harm  in  another 
way;  by  overstuffing  the  lymph-glands,  giving  them  more  than 
they  can  do;  choking  them  with  their  own  materials,  and  leading 
directl}'  to  tabes  mesenterica,  bronchial  glandular  enlargement, 
and  even,  I  believe,  to  a  general  disease  in  the  glandular  elements 
in  many  parts — a  process  which,  at  its  onset,  is  more  aptly  com- 
pared to  stuffing  turkej'S  or  geese  than  to  any  strictly  pathological 
condition."* 

The  physiology  of  nerve  stimulation  and  reflex  action  is  com- 
plex, and  in  no  respect  can  be  more  complicated  than  with  regard 
to  the  functions  of  the  nerves  controlling  respiration.  It  is  now 
considered  probable  that  the  grave  reflex  results  due  to  this  disor- 
der are  not  invariably  confined  to  spasm  of  the  laryngeal  muscles. 
The  mischief  appears  to  lie  in  the  bronchioles  and  the  lung  itself, 
a  condition  "  closel}^  allied,"  as  Dr.  Goodhart  remarks,  "  to  what 
we  suppose  to  be  the  case  in  spasmodic  asthma."  With  the  knowl- 
edge of  this  fact,  the  practitioner  becomes  aware  of  the  futility  of 
attempting  tracheotomy  in  ordinary  cases  of  enlargement  of  the 
bronchial  glands.  But  hard-and-fast  rules  cannot  be  founded  on 
ph^'siological  hypotheses.  In  verj^  severe  and  sudden  fits  of  dysp- 
noea from  the  disease  now  claiming  our  attention,  it  may  happen 
that  a  gland  has  ulcerated  into  the  bronchus,  become  detached, 
and  produced  the  same  spasm  of  the  glottis  which  follows  the 
entrance  of  cherry-stones  or  other  foreign  bodies  into  the  air-pas- 
sages. The  well-known  fatal  case  from  this  cause,  in  a  boy  aged 
eight  years,  described  by  Mr.  Edwards  in  the  thirty-sixth  volume 
of  the  Medico-Chirurgical  Iransactions^  and  quoted  in  Holmes's 
System  of  Surgery,  might  have  recovered  if  tracheotomy  could 
have  been  performed  earlier. 

On  post-mortem  examination,  the  appearances  of  the  aftected 
region  are  readily  made  out  by  any  observer  who  has  had  a  fair 
idea  of  the  normal  size  of  the  bronchial  and  mediastinal  glands. 
From  their  position  (especially  as  regards  those  at  the  root  of  the 
lung)  it  may  readilj^  be  seen  to  what  extent  they  press  on  neigh- 
boring vessels  and  nerves.  Dr.  Goodhart,  in  one  case,  found  the 
pneumogastric  nerve  firmly  adherent  to  a  diseased  gland.     The 

*  Cases  of  Enlargement  or  Inflammation  of  the  Mediastinal  Glands,  Brit.  Med. 
Journ.,  vol.  i.  1879,  p.  5S0. 

25 


38  G  DISEASES   OF   CHILDREN. 

patient  was  a  boy,  aged  eight,  who  died  after  sufFeriug  from 
severe  paroxysms  of  dyspnoea  for  a  fortnight.  The  same  authority 
describes  an  autopsy  where  the  thymus  gland  was  found  much 
enlarged.  The  patient,  an  infant  eight  months  old,  had  been  sub- 
ject to  convulsions  and  fits  of  choking.  Irritation  of  the  medias- 
tinal nerves  by  the  large  thj^raus  had  probably  exercised  a  con- 
siderable share  in  the  fatal  result.  The  trachea  and  bronchi  may 
be  ulcerated  by  pressure  of  the  glands,  and  even  plugged  by  them. 

The  symptoms  belonging  to  enlarged  mediastinal  glands  are 
spasmodic  fits  of  coughing,  causing  lividity  of  the  features,  and 
threatening  asphyxia.  Other  cases  begin  with  catarrh  and  febrile 
disturbance,  which  may  last  for  a  week,  and  then  spasmodic  cough 
and  crowing  inspiration  ensue.  The  child  cannot  lie  down  in  bed 
for  fear  of  choking,  and  he  is  in  constant  danger  of  suflbcation. 

The  chief  symptoms  are  those  of  bronchial  irritation.  Wheez- 
ing, with  attacks  of  dyspnoea,  sometimes  amounting  to  spasmodic 
asthma,  is  very  general  in  these  cases.  The  fits  of  coughing  are 
not  unlike  those  of  whooping-cough,*  and  in  some  instances  the 
child  seems  as  though  it  could  not  get  breath,  and  dies  of  asphyxia. 
After  death  in  such  cases,  enlarged  caseous  glands  are  found  in 
the  mediastinum,  and  near  the  bifurcation  of  the  bronchi.  In  the 
case  of  a  child,  two  and  a  half  ^^ears  old,  recorded  by  Dr.  Good- 
hart,  a  large  caseous  gland  had  opened  into  the  trachea,  and 
caused  death.f  The  mesenteric  glands  were  also  enlarged,  and 
Peyer's  patches  were  thickened,  whilst  the  mucous  membrane 
generally  over  this  part  of  the  ileum  was  thickened,  and  the  glands 
were  in  a  state  of  overgrowth.  In  another  case  related  by  him, 
the  thymus  gland  was  very  large,  and  where  the  inferior  larj' ngeal 
nerve  is  given  ofl:'  from  the  par  vagum  there  was  an  enlarged  gland, 
the  size  of  a  "haricot  bean,"  imbedded  in  the  surrounding  fibrous 
tissue.  The  glands  about  the  root  of  the  lung  and  vagus  were 
equally  large,  but  not  caseous. 

An  attack  of  difiicult  breathing,  like  asthma,  may  come  on, 
accompanied  with  lividity  of  the  features,  paroxysmal  cough, 
staring  eyes,  painful  anxiety,  and  end  in  death  by  coma.  In  such 
a  case  there  may  be  caseous  and  suppurating  glands,  with  broncho- 
pneumonia. 

*  See  Chap.  XXXII,  On  Pertussis. 

t  Cases  of  Enlargement  or  Inflammation  of  the  Mediastinal  Glands,  Brit.  Med. 
Journ.,  vol.  i,  1879,  p.  542. 


ENLARGED    BRONCHIAL    AND    MEDIASTINAL    GLANDS.  387 

I  have  seen  the  disease  in  connection  with  rickets,  acnte  tuber- 
culosis, and  emphysema.  The  following  is  a  very  instructive  and 
interesting  case,  and  the  examination  after  death  confirms  the 
diagnosis  which  was  made  when  the  child  first  came  under  treat- 
ment. 

C.  J ,  ret.  If,  was  brought  to  me  on  January  3d,  1876,  at 

the  Samaritan  Hospital,  as  an  out-patient,  with  the  following  his- 
tory: In  September,  1875,  he  was  seized  with  cough,  breatbless- 
■ness,  and  febrile  disturbance,  having  been  up  to  this  time  strong 
and  well.  The  father  and  mother  were  healthy,  and  there  was  no 
phthisis  in  the  family.  The  child  was  pallid,  with  gray  eyes,  light 
hair,  and  prominent  forehead.  He  liad  sixteen  teeth,  which  were 
decayed  and  ragged,  and  the  gums  were  red  and  spongy.  The 
thorax  was  thin  and  rounded,  and  the  ribs  were  very  prominent 
from  loss  of  flesh  ;  beneath  both  clavicles  the  percussion-note  was 
liyper-resonant,  especially  on  the  left  side ;  posteriorly  the  note 
was  tympanitic  between  the  scapulae  at  the  upper  part,  and  the 
breathing  was  almost  cavernous  between  the  spine  of  the  right 
scapula  and  vertebral  column,  but  there  was  no  moist  crepitation. 
I  diagnosed  an  empty  cavity  in  this  situation.  Temperature 
102.6°;  pulse  160,  small;  respirations  80,  short  and  superficial. 

The  head  was  large,  and  the  veins  over  the  forehead  and  temples 
distended.  He  was  not  admitted  into  the  hospital,  as  the  mother 
preferred  keeping  him  at  home.  He  was  ordered  a  diet  of  milk 
and  beef  tea,  and  in  the  shape  of  medicine  a  mixture  every  four 
hours,  consisting  of  carbonate  of  ammonia  and  tincture  of  cin- 
chona, wnth  syrup  of  tolu  and  water. 

February  3d. — He  was  better  for  a  time,  in  consequence  of  the  di- 
rections being  carefully  carried  out,  but  he  relapsed  again  yesterday 
afternoon,  was  hot,  and  had  headache,  sweating  and  perspiration 
of  the  scalp  ;-the  child  had  evidently  been  in  great  pain,  judging 
from  the  rolling;  of  the  head  to  and  fro.  The  mother  stated  that 
he  was  always  feverish,  with  flushed  cheeks  in  the  evening ;  but 
the  temperature  was  only  98°,  pulse  132,  respirations  56.  Loud 
rhonchus  and  catarrhal  sounds  were  heard  throughout  the  chest, 
both  in  front  and  behind  ;  there  was  loose  gurgling  heard  over  the 
suspected  cavity  or  suppurating  gland  at  the  upper  part  of  the 
left  scapular  region,  close  to  the  vertebrae.  The  child  was  very 
fidgety,  irritable,  and  quarrelsome.  Two  grains  of  bromide  of 
potassium  were  added  to  each  dose  of  the  mixture,  and  a  teaspoon- 


388  DISEASES    OF    CHILDREN. 

ful  of  sjTup  of  senna  was  given  occasionally  to  keep  the  bowels 
freely  open. 

14th. — He  had  greatly  improved  up  to  this  date,  and  was  much 
better ;  had  had  no  feverish  attack  since  the  6th,  but  his  cough 
vv^as  very  troublesome,  and  he  was  rapidly  losing  flesh ;  he  was 
never  sick ;  temperature  99°,  pulse  132,  respirations  48.  The 
cough  w^as  less,  and  tbe  breathing,  thoagh  quick,  was  easier,  and 
more  indicative  of  debility  than  pulmonary  embarrassment ;  face 
very  pallid,  pupils  large,  eyes  bright,  skin  of  arms  and  legs  loose, 
and  both  limbs  much  wasted.  To  continue  the  mixture,  and  take 
a  teaspoonfal  of  cod-liver  oil  twice  a  day. 

22d. — The  mother  feared  the  child  had  v^hooping- cough,  as  his 
sister  was  suffering  severely  from  it,  though  she  had  not  heard 
him  whoo^D ;  he  coughed  up  much  phlegm  of  a  stringy  tenacious 
character.  He  was  so  restless  and  fretful  that  it  was  diflScult  to 
count  the  pulse.  After  some  trouble  I  made  out  the  temperature 
in  the  rectum  99.8°,  pulse  140,  respirations  52.  The  bromide  was 
again  increased  to  four  grains  three  times  a  day. 

24th. — Xot  so  well,  the  cough  being  too  incessant  and  trouble- 
some for  him  to  obtain  any  rest  or  sleep  at  night ;  there  were  loud 
mucous  rales  throughout  the  chest,  and  though  he  did  not  whoop, 
the  violence  of  the  cough  was  suspicious.  He  was  much  more 
manageable,  and  did  not  move  when  the  thermometer  was  put 
into  the  rectum.  He  w^as  ordered  three  grains  of  bromide  of 
potassium  and  two  grains  of  hydrate  of  chloral,  to  be  taken  every 
night  at  bedtime. 

28th. — jSTo  rest  since  last  visit ;  for  an  hour  or  two  he  seemed  as 
though  he  would  lapse  into  unconsciousness.  Though  he  had  not 
whooped,  the  cough  was  incessant  and  tearing,  and  the  perspira- 
tion poured  off  his  head.  The  feet  and  hands  were  inclined  to 
swell ;  the  eyes  had  a  staring  and  wild  look,  and  the  rolling  mo- 
tion of  the  head  indicated  cerebral  trouble.  There  could  be  no 
doubt  that  whooping-cough  was  a  complication. 

29th. — He  appeared  better,  and  ate  some  pudding,  shortly  after 
which  he  was  seized  with  a  choking  cough,  turned  rather  dusky, 
and  then  died  suddenly,  without  any  sign  of  struggling. 

Post-mortem.  Examination  (twenty-four  hours  after  death). — Body 
thin  and  pale,  with  livid  marks  posteriorly.  On  opening  the  tho- 
racic cavity,  the  lungs  were  found  to  be  approximated  at  the  an- 
terior  borders,  pallid,  and   very  emphysematous,  especially  the 


ENLARGED    BROXCIIIAL   AND    MEDIASTINAL    GLANDS.  389 

upper  lobes.  At  the  upper  and  posterior  portion  of  the  right  lung, 
close  to  the  spine,  where  gurgling  was  heard  when  the  child  first 
came  under  notice,  was  a  caseous,  suppurating  bronchial  gland, 
from  which  about  a  teaspoonful  of  yellow  cheesy  matter  was 
squeezed  out ;  the  entire  half  of  this  lung,  when  cut  into,  con- 
tained many  semi-transparent  gray  granulations,  and  the  whole 
lung-tissue  in  this  situation  was  pallid,  and  of  a  light  rosy  hue ; 
many  of  the  air-cells  had  ruptured.  The  left  lang  was  more  pallid 
and  emphysematous ;  it  contained  here  and  there  a  few  gray  gran- 
ulations and  very  minute  cavities,  irregularly  and  scantily  dis- 
tributed, some  the  size  of  a  pin's  head. 

The  pericardium  contained  some  thin  serous  fluid,  and  the  ves- 
sels on  the  outer  surface  of  the  heart  w^ere  full.  In  the  right  ven- 
tricle was  a  clot  of  fibrin,  as  big  as  a  small  walnut,  and  some  dark 
blood  ;  to  it  was  attached  a  cord  of  fibrin,  six  inches  long,  with  a 
branch  going  into  the  pulmonary  artery,  and  this  might  have 
been  the  cause  of  sudden  death,  although  p»ost-mortem  clots  are 
very  frequent  in  this  vesseh  The  kidneys,'  spleen,  and  mesen- 
tery w^ere  healthy,  and  no  tubercle  was  detected.  The  liver  was 
large,  extending  into  the  left  hj^pochondriac  region  ;  no  sign  of 
tubercle. 

The  brain-structure  was  soft  and  pallid;  it  was  considerably 
enlarged,  and  the  sinuses  at  the  base  were  very  full  and  distended, 
but  nothing  like  albuminous  or  sero-purulent  matter  was  to  be 
observed  around  any  of  the  nerves  where  it  is  usually  seen  in 
meningitis,  and  no  excess  of  fluid  was  present.  The  brain,  hov»- 
ever,  was  altogether  more  watery  than  usual.  There  was  no  tu- 
bercles anywhere,  nor  an^^  fluid  in  the  ventricles. 

Note. — The  immediate  cause  of  death  was  probably  the  obstruc- 
tion of  the  pulmonary  and  systemic  circulations  by  the  entrance 
of  the  clot  into  the  pulmonary  artery,  and  so  the  heart  failed. 

The  next  case,  though  it  did  not  terminate  fatally,  illustrates 
all  the  clinical  features  of  enlarged  bronchial  glands. 

A.  N ,  set.  4,  was  admitted  into  the  Samaritan  Hospital  on 

October  29th,  1877.  He  had  been  ill  three  weeks  with  a  bronchial 
attack  and  cough.  On  admission  the  temperature  was  101°,  pulse 
132,  respiration  31.  After  a  purge  and  a  saline  mixture  the  tem- 
p)erature  fell  to  99.4°  in  twenty-four  hours,  and  two  days  later  it 
was  normal. 

The  cervical  glands  on  the  left  side  were  so  large  that  they  ob- 


390  DISEASES    OF    CHILDEEN. 

literated  tlie  ramus  of  the  lower  jaw  and  filled  up  the  space  in  the 
neck.  On  the  right  side  they  were  also  large,  but  much  less  so 
than  on  the  left. 

The  patient  had  a  shrill,  whistling,  choking  cough,  but  varied  a 
good  deal  in  character,  being  sometimes  like  croup,  and  at  others 
resembling  a  "Punch-aud-Judj"  squeak.  He  was  unable  to  as- 
sume a  recumbent  posture,  but  sat  up  in  bed  with  his  head  bent 
forwards.  His  breathing  -was  frequent  and  noisy,  and  wdieezing 
was  particularly  loud  after  coughing  or  taking  food.  Over  the 
upper  sternum  and  along  its  centre  the  percussion-note  was  very 
resonant.  The  resonance  was  impaired  and  the  breathing  weak 
under  the  clavicles.  There  were  loud  laryngeal  moist  sounds,  the 
respiration  was  diaphragmatic,  and  the  lower  part  of  the  sternum 
was  drawn  in  at  each  inspiration.  Posteriorly  there  was  dulness 
over  the  upper  lobes  of  the  lungs,  especially  on  the  right  side, 
between  the  spine  and  upper  edge  of  the  scapula;  resonance  was 
well  marked  below,  but  throughout  there  was  rhonchus,  mixed 
with  large  and  loose  crepitation.  Sometimes  the  respiration  was 
placid  and  noiseless,  particularly  in  the  daytime;  but  in  the  even- 
ing, or  during  the  night,  the  breathing  was  occasionally  difficult, 
and  resembled  an  attack  of  spasmodic  asthma. 

The  treatment  consisted  in  giving  the  syrup  of  iodide  of  iron, 
cod-  liver  oil,  and  good  diet.  A  weak  solution  of  tincture  of  iodine 
was  applied  to  the  glands  in  the  neck,  and  between  the  shoulders 
at  the  upper  part  of  the  scapulas. 

The  condition  varied  a  good  deal  for  the  first  three  weeks,  but 
on  the  28th  of  Is'ovember  the  glands  in  the  neck  had  much  de- 
creased in  size,  and  although  the  face  was  bloated  it  was  not 
dusky. 

December  28th.  The  child  had  in  all  respects  improved;  he  was 
lively  and  cheerful,  enjoying  his  food,  and  sleeping  tranquillj^  at 
night.  He  could  lie  with  his  shoulders  low,  or  on  either  side, 
W'ithout  causing  cough  or  inconvenience  in  breathing.  The  chest 
w^as  everywhere  resonant,  inspiration  was  freer  and  longer,  whilst 
expiration  was  much  shorter,  and  there  were  no  moist  sounds  to 
be  heard,  though  there  was  considerable  rhonchus.  Pulse  88; 
respiration  20.  The  diminution  in  the  size  of  the  glands  in  the 
neck  was  remarkable. 

Caseous  degeneration  of  the  bronchial  glands  has  been  found  in 
connection  with  tuberculosis  of  the  lungs,  as  we  have  just  seen. 


EXLAEGED    BrwONCHIAL   AND    MEDIASTINAL   GLANDS.  391 

There  is  a  case  recorded  by  the  late  Dr.  Pearson  Irvine  in  T\-hich 
it  was  associated  Avith  tubercle  in  the  lungs,  brain,  and  kidneys. 
In  a  boy,  set.  7  years,  "a  tumor"  was  found  beneath  the  thyroid 
body  after  death  as  large  as  a  walnut;  the  bronchial  ghands  were 
swollen  and  caseating,  whilst  the  upper  lobes  of  both  lungs  cod- 
tained  gray  granulations,  some  being  small  and  translucent  and 
others  larger  and  undergoing  caseation.  The  lower  lobes  of  the 
lungs  and  the  kidneys  also  contained  scattered  tubercles.  At  the 
base  of  the  skull  there  were  about  eight  ounces  of  serous  effusion, 
and  near  the  posterior  end  of  the  falx  cerebri  "  a  mass  about  the 
size  of  a  large  Barcelona  nut."  There  were  no  tubercles  at  the 
base  of  the  brain,  but  they  were  numerous  in  the  cerebrum, "  vary- 
ing in  size  from  a  marble  to  a  small  walnut,"  and  they  were  also 
met  with  in  the  cerebellum.  Notwithstanding  these  changes,  this 
boy  never  experienced  any  cough  from  the  beginning  to  the  end 
of  his  illness."'^ 

Another  singular  case  is  recorded  by  Dr.  Sydney  Coupland,t  in 
which  a  caseous  mediastinal  gland  burst  into  the  trachea,  causing 
death  in  a  paroxysm  of  dyspnoea.  The  patient,  a  delicate  boy 
four  3'ears  of  age,  was  said  to  be  "  asthmatical"  shortly  after  birth ; 
later  on,  when  two  years  old,  he  had  "low^  fever,"  lasting  seven 
weeks.  When  three  years  old  he  took  cold,  and  suffered  from 
alarming  attacks  of  shortness  of  breath,  general  bronchitis,  and 
hoarse  rino-ino-  couo;h.  Under  treatment  he  became  convalescent, 
and  left  the  hospital.  Xine  days  later  he  was  readmitted  with 
bronchitis,  and  soon  afterwards  suffered  from  paroxysmal  attacks 
of  dyspnoea,  inability  to  lie  down,  and  lividity  of  the  lips.  During 
one  of  these  seizures  Mr.  Morris  performed  tracheotomy,  which 
quieted,  the  breathing  for  a  time,  but  in  a  month  from  the  date 
of  his  readmission  another  attack  occurred,  and  the  child  died 
asphyxiated. 

On  a  post-mortem  examination,  there  was  found  a  collection  of 
enlarged  and  indurated  glands  in  the  anterior  mediastinum,  mostly 
near  the  root  of  the  right  lung.  In  the  posterior  mediastinum 
there  was  a  chain  of  enlarged  glands,  and  above  the  right  bronchus 
the^^  had  formed  a  mass  of  caseous  matter.  "  On  laying  open  the 
trachea,  that  tube  was  found  to  be  occluded  just  above  the  poiutr 

*  Path.  Trans.,  vol.  xxix,  p.  11.     It  somewhat  resembles  Mr.  Edwards's  case  already 
quoted,  p.  385. 
t  Ibid.,  vol.  XXV,  p.  29. 


392  DISEASES   OF  CHLLDREX. 

of  bifurcation  bj  a  mass  of  claeesy  matter  extending  into  the  riglit 
bronclius,  and  proceeding  from  the  largest  mass  in  the  mediastinum, 
■which  had  ulcerated  through  the  trachea  at  this  point,  the  aper- 
ture measuring  nearly  an  inch  along  the  axis  of  the  tube,  while, 
for  more  than  half  an  inch  above,  the  calibre  of  the  channel  was 
narrowed  bj  the  pressure  of  the  gland  from  without."  There  was 
a  cavity  in  the  right  apex,  the  bronchi  were  dilated,  and  the  lung- 
tissue  was  more  or  less  solidified.  There  was  some  enlargement 
of  the  mesenteric  glands. 

Treatment. — This  must  be  conducted  on  general  principles.  If 
there  are  indications  of  bronchitis  or  pulmonary  congestion,  they 
must  be  controlled  by  sedatives  and  counter-irritants ;  febrile 
symptoms  demand  salines  and  mild  aperients  (Forms.  7,  8,  12). 
Carbonate  of  ammonia,  senega,  and  ipecacuanha  should  be  selected 
to  relieve  cough  and  oppression  in  breathing  (Forms.  61-66). 
"When  the  case  is  not  associated  with  any  acute  febrile  disorders, 
as  tubercle,  whooping-cough,  or  measles,  but  only  accompanies 
loss  of  flesh  and  strength,  failing  appetite,  and  general  wasting, 
then  cod-liver  oil,  malt  extract,  and  the  syrup  of  the  iodide  of  iron, 
are  the  remedies  best  calculated  to  afford  relief. 

"When  bronchial  symptoms  are  present,  and  there  is  pain  in  the 
chest,  the  application  of  a  small  linseed  poultice  with  a  table 
spoonful  of  mustard  for  a  few  minutes  at  bedtime  may  be  neces- 
sary, the  chest  being  afterwards  protected  with  cotton-wool. 
Another  form  of  local  application  consists  of  a  stimulating  and 
sedative  liniment,  comjiosed  of  equal  parts  of  aconite  and  camphor 
liniment,  or  of  belladonna  liniment  and  spirit  of  chloroform, 
sprinkled  on  a  piece  of  flannel  wrung  out  of  hot  water,  and  ap- 
plied under  a  folded  towel  or  on  spongiopiliue.  This  will  relieve 
pain  in  the  chest  when  present,  just  as  it  will  mitigate  the  sufter- 
ing  of  sciatica  in  adults. 

When  the  enlarged  glands  have  passed  into  a  chronic  state,  the 
application  of  diluted  tincture  of  iodine  (1  in  4)  may  be  advanta- 
geously^ resorted  to.  It  is  remarkable  how  the  hypertrophied  cer- 
vical and  bronchial  glands  sometimes  become  diminished  in  size 
under  the  persevering  use  of  this  valuable  absorbent,  combined 
with  good  diet,  pure  air,  and  such  internal  remedies  as  the  circum- 
stances of  the  case  may  appear  to  warrant. 


ON   ASTHMA.  393 

CHAPTER   XXXIV. 

ON   ASTHMA. 

Causes  :  Predisposing  and  exciting — Sometimes  hereditary — Its  neurosal  origin — Follows 
u-hooping-cough,  bronchitis,  and  measles — An  occasional  sequel  to  scarlet  fever — Some- 
times excited  by  certain  fungi — Odors  of  plants  and  animals — Irritation  of  dust,  etc. — 
Indigestion.  Symptoms:  Frequently  comes  on  suddenly  at  night  during  sleep — 
Symptoms  of  a  paroxysm — Rapid  breathing — Anxious  countenance — Inspiration  short 
— Expiration  prolonged — Duration  of  the  fit — 3Iay  begin  vnth  catarrh — Association 
iL'ith  gout — Albuminuria.  Diagnosis:  General  absence  of  fever — Suddenness  of  the 
pai-oxysms,  and  recurrence  at  uncertain  intervals — Tranquil  rkspiration  between  the 
attacks — Dyspnoea  of  asthma  gradual  and  decline  rapid — Cardiac  dyspnoea  always 
increased  by  exertion,  and  patient  not  so  well  after  a  seizure  as  after  an  asthmatic  attack. 
Prognosis  :  Favorable  in  young  subjects,  and  when  disease  arises  from  hypertrophy  of 
bronchial  glands —  Unfavorable  in  tubercular,  cardiac,  or  renal  cases.  Pathology  : 
Essential  cause  of  asthma  consists  in  a  spasmodic  contraction  of  the  muscular  walls  of 
the  bronchial  tubes — A  true  pulmonary  neurosis  accompanied  by  catarrh,  not  necessarily 
by  any  fever.  Treatment  :  Apartments,  and  especially  sleeping-rooms,  to  be  large 
and  airy — Action  of  remedies  very  uncertain —  Use  of  expectorants  where  there  is  much 
secretion  and  congestion — Nitre-paper  fumes — Belladonna — Stramonium — Hydrate  of 
chloral — Ipecacuanha — Strong  coffee — Arsenic — Iron — Cod-liver  oil — Inhalation  of 
iodide  of  ethyl  and  of  chloroform  to  arrest  a  paroxysm — Injection  of  pilocarpin — Spray 
inhalation  of  carbolic  acid,  etc. —  Care  necessary  in  diet — Avoidance  of  stimulants — 
3Iild  aperients — Gentle  exercise — Baths — Sea  air — Gymnastics. 

Asthma  is  one  of  the  most  peculiar  and  intractable  of  diseases, 
consisting  of  a  paroxysmal  form  of  dyspnoea,  with  tranquil  respira- 
tion in  the  intervals  of  the  seizures.  It  does  not  necessarily  depend 
upon  organic  or  structural  change  in  any  part  of  the  thoracic 
organs,  and  hence  it  has  been  looked  upon  as  a  purely  nervous 
affection  ;  although  it  would  appear  that  the  integrity  of  the 
pulmonary  tissue  does  become  impaired  and  the  heart  diseased 
when  the  paroxysms  are  frequent,  and  the  complaint  is  of  long 
continuance. 

Xeither  West,  Underwood,  Meigs  and  Pepper,  Steiner,  Churchill, 
nor  Xiemej'er,  alludes  to  asthma  in  childhood,  which  seems  to  me 
an  omission,  seeing  that  however  infrequent  it  may  be  at  an  early 
period  of  life,  it  occurs  sufficiently  often  to  require  consideration 
and  careful  study.  Trousseau,  Hyde  Salter,  Thorowgood,  and 
Berkart,  enter  into  the  subject  of  asthma  in  children.  It  is  rare 
in  hospital  practice.  I  have  only  seen  a  few  cases,  and  none  of 
these  were  under  ten  years  of  age. 

Causes. — These  are  predisposing  and  exciting.     The  disease  is 


394  DISEASES    OF    CHILDEEX. 

hereditary,  running  through  families  with  as  much  regularity  as 
tubercle,  or  gout  itself.  It  occurs  in  the  children  of  parents  who 
are  hysterical,  or  whose  nervous  sj'stem  is  highly  impressible.  To 
a  child  so  predisposed  any  exertion  or  emotion  will  be  enough  to 
invite  a  paroxysm,  solely  through  the  efiect  it  produces  upon  the 
.nervous  system,  notwithstanding  that  the  lungs  themselves  are 
perfectly  sound. 

Asthma  follows  whooping-cough,  bronchitis,  and  measles;  and 
the  inference  to  be  derived  from  this  fact  is,  that  the  lungs  in  such 
cases  have  sustained  damage  which  disposes  them  to  asthma.  The 
bronchial  mucous  membrane  undergoes  some  inappreciable  patho- 
logical change,  and  its  sensibility  becomes  morbidly  increased. 
"  These  diseases  are,  beyond  a  doubt,  the  commonest  of  all  the 
causes  of  asthma ;  a  large  proportion  (as  much  as  80  per  cent.)  of 
cases  of  asthma  in  the  young  date  from  one  or  other  of  them."* 
"Like  all  hereditarj^  disorders,"  says  Dr.  Fuller,  "it  may  occur  at 
any  period  of  life,  and  instances  are  not  wanting  of  its  existence 
in  infancy  and  early  youth.  One  of  the  most  frightful  examples 
of  it  I  ever  met  with  was  in  the  person  of  a  boy  thirteen  years  of 
asre.  Indeed,  it  often  dates  its  orio-in  from  the  diseases  of  child- 
hood,  from  the  straining  efforts  incident  to  whooping-cough,  and 
the  severe  bronchitis  which  accompanies  measles. "f  Dr.  Thorow- 
good  relates  the  case  of  a  child,  aged  four,  who  got  an  attack  of 
asthma  after  scarlet  fever,  though  there  was  no  anasarca,  the  urine 
only  contained  lithates,  and  no  albumen.  At  nine  he  was  still 
under  treatment,  and  more  relief  was  obtained  from  a  drj-  bracing 
air  than  from  any  medicine. 

The  exciting  causes  of  asthma  are  numerous,  and  they  vary  in 
different  jjersons — that  which  will  excite  the  paroxysm  in  one 
person  will  not  do  so  .in  another.  Irritant  substances,  such  as  dust, 
offensive  smells,  and  cold  air  admitted  into  the  air-passages  in 
respiration,  are  common  excitants  of  the  asthmatic  paroxysm  ; 
they  appear  to  irritate  and  offend  the  bronchial  mucous  mem- 
brane, and  thus  to  excite  convulsive  cough  and  d3'spnoea.  Trous- 
seau, who  himself  was  a  sufferer  from  asthma,  attributes  the 
worst  attack  he  ever  had  to  the  dust  from  oats,  which  were  being 
measured  in  his  presence,  penetrating  into  the  bronchi.  He  relates 
cases  caused  by  the  thrashing  of  rice,  the  shaking  of  a  feather 

*  On  Asthma,  by  Dr..  Hyde  Salter,  18G0,  p.  130. 
f  Diseases  of  the  Lungs,  1867,  p.  368. 


ON   ASTHMA.  395 

bed  in  the  presence  of  an  asthmatic  patient,  the  odor  of  ipecacu- 
anha, linseed,  or  scammony,  scents  of  any  kinds,  the  perfume  of 
violets  and  some  other  flowers.  Season,  climate,  and  temperature 
have  also  a  powerful  influence  in  the  production  of  asthma.  The 
smell  of  cats,  dogs,  and  hare-skins,  seems  to  be  capable  of  causing 
the  paroxysm  in  some  persons.  Some  asthmatic  patients  cannot 
sleep  out  of  London,  and  others  can  only  obtain  rest  in  certain 
districts.  Trousseau  relates  the  circumstance  of  two  brothers 
who  were  twins,  and  of  remarkable  physical  likeness.  When  one 
had  an  attack  of  ophthalmia  in  Paris,  the  other,  who  was  in  Vi- 
enna at  the  time,  was  also  suftering  in  preciselj^  the  same  manner. 
Both  were  subject  to  fearful  asthma  in  Marseilles,  where  they 
were  born  ;  but  in  Paris  they  were  free.  When  one  was  afltected 
the  other  was  also,  and  both  experienced  immunity  in  the  same 
localities.'" 

Irritation  of  the  air-tubes  by  the  inhalation  of  dust  may  cause 
a  certain  degree  of  thickening  and  contraction  of  the  bronchial 
tubes,  but  it  is  not  of  itself  enough  to  provoke  the  asthmatic  par- 
oxysm. W^e  know  that  this  is  so  in  mining  and  manufacturing 
districts,  where  workmen  are  exposed  to  such  inhalation  during 
the  chief  portion  of  their  lives.  The  tendency  is,  however,  in 
them,  to  effect  an  alteration  in  the  mucous  membrane  (mechani- 
cal bronchitis)  and  the  structure  of  the  lungs,  and  not  to  produce 
spasmodic  narrowing,  and  the  resultant  asthma.  Certain  indi- 
gestible articles  of  diet,  as  cheese  and  nuts,  may,  by  irritating  the 
pneuraogastric  nerve  in  the  stomach,  excite  reflex  spasm  in  the 
bronchial  tubes.  In  a  large  number  of  cases  the  attack  comes  on 
without  apparent  cause. 

The  influence  which  the  stomach  exercises  in  provoking  an 
attack  of  asthma  is  very  remarkable  ;  but  it  is  no  more  than  we 
might  expect  when  we  consider  that  there  is  a  close  connection 
between  the  lung  and  the  stomach  through  the  medium  of  the 
pneumogastric.  In  asthmatic  cases  the  stomach  is  generally  irri- 
table and  the  appetite  irregular.  Salter  relates  the  case  of  a  little 
girl,  eight  years  of  age,  who  vomited  everything  immediatelj^  it 
was  swallowed,  but  without  pain  or  tenderness.  This  continued 
for  years,  and  caused  great  weakness  and  emaciation.  Nothing, 
except  teaspoonfuls  of  milk,  could  be  retained  on  the  stomach. 

*  Clin.  Med.,  vol.  i,  1867,  p.  630. 


396  DISEASES   OF   CHILDEEN. 

At  lenstli  the  vomitins:  ceased  and  asthma  besran.  The  irritation 
was  transferred  from  the  gastric  portion  of  the  pneumogastric  to 
the  pulmonary  portion.*  Eating  late  in  the  daj'  will  sometimes 
provoke  a  paroxysm,  while  an  early  dinner,  and  taking  no  solid 
food  till  next  dsij  will  ward  it  off. 

Symptoms. — The  child,  as  is  the  case  with  an  adult,  may  seem 
to  retire  to  bed  in  good  health,  and  an  attack  may  come  on  in  the 
night,  which  is  the  most  usual  time.f  The  patient  drops  off  to 
sleep,  and  after  an  uncertain  interval  wakes  up  frightened  with 
an  attack  of  dyspnoea  and  inability  to  get  his  breath.  Pain,  or  a 
sense  of  constriction  is  felt  across  the  chest.  He  feels  suffocated, 
and  is  anxious  to  get  all  the  air  he  can  obtain  ;  hence  he  may  run 
to  an  open  window,  or  he  at  least  sits  up  in  bed  with  his  arms 
thrown  backwards,  or  he  kneels,  or  is  propped  up  in  a  chair,  with 
his  thorax  and  clavicles  fixed  and  drawn  upwards.  The  face  is 
flushed  or  of  a  pale  livid  hue,  and  fearfully  anxious ;  the  skin  is 
bathed  in  sweat,  the  eyes  are  staring  and  prominent,  and  the 
extremities  cold.  The  pulse  may  be  rapid,  and  the  respirations 
GO  to  70  per  minute.  The  chest  is  elevated,  rounded,  and  reso- 
nant, with  scarcely  any  expansible  movement ;  the  epigastrium  is 
retracted  from  elevation  of  the  diaphragm,  whilst  the  lower  ribs 
are  retracted  during  inspiration.  The  expiration  is  prolonged 
and  wheezing,  the  inspiration  is  short,  frequent,  and  sometimes 
convulsive.  Sonorous  and  sibilant  rhonchi  usurp  the  place  of  the 
normal  respiratory  murmur. 

The  fit  may  last  half  an  hour  in  mild  cases,  or  two  or  three 
hours  in  severe  ones.  Then  it  passes  off,  the  face  assumes  a 
natural  appearance,  and  the  child  is  himself  again.  During  the 
fit  the  urine  is  copious  and  clear,  but  v,hen  it  has  terminated  it  is 
scanty  and  turbid.  Sleep  generally  follows  the  attacks.  A  sense 
of  heaviness,  weight  at  the  chest,  and  dyspeptic  symptoms  succeed, 
to  be  followed  night  after  night  by  similar  attacks.  The  fre- 
quency of  return  is  uncertain,  the  interval  may  be  weeks  or 
months  ;  in  exceptional  cases  years  may  elapse. 

The  disease  often  begins  with  catarrh,  constant  sneezing,  run- 
ning of  the  eyes  and  nose ;  and  these  symptoms  may  have  preceded 
the  asthmatic  paroxysm  by  some  days.  This  is  frequently  the 
case  with  children.     In  these  cases  there  is  urgent  dyspnoea  and 

*  Op.  cit.,  p.  218. 

f  "  In  some  cases  the  attacks  are  diurnal  instead  of  nocturnal." — Tromseau. 


ON   ASTHMA.  397 

inability  to  lie  down ;  the  normal  respiratory  murmur  is  replaced 
by  sonorous  and  mucous  rlionchi,  which  gradually  cease  after  the 
paroxysm  is  over. 

Trousseau  describes  a  case  of  an  opposite  character  in  a  child. 
'^  The  patient  was  a  Moldavian  bo}^,  aged  5,  who  had  very  distinct 
and  well-characterized  fits  of  asthma,  together  with  some  pul- 
monary emphysema.  In  his  family  history  there  was  no  mention 
of  any  hereditary  taint  of  gout  or  of  rheumatism.  I  saw  him 
again  two  years  afterwards  ;  he  had  then  a  most  characteristic  fit 
of  the  gout,  with  redness,  swelling,  and  pain  in  the  big  toe.  This 
was  the  first,  and  has  been  the  last  instance  I  have  ever  seen  of 
gout  at  such  an  early  age.  The  gouty  arthritis  attacked  the 
knees,  and  had  not  the  slightest  resemblance  to  acute  articular 
rheumatism.  During  this  attack  of  gout  the  boy  had  not  a  single 
paroxj^sm  of  asthma.  The  disease  ran  its  usual  course,  for,  as  I 
will  tell  you  by-and-bj^,  gout  and  asthma  are  often  manifestations 
of  one  and  the  same  diathesis,  and  they  may  alternate  in  the  same 
individual,  as  the^^  did  in  my  Moldavian  patient."*  Asthmatic 
seizures  have  owed  their  origin  to  albuminuria  and  pulmonary 
oedema,  accompanying  some  forms  of  Bright's  disease. f 

Diagnosis. — When  there  are  inflammatory  symptoms  present  in 
the  bronchial  tubes,  and  a  great  deal  of  secretion  is  poured  out, 
the  real  cause  of  the  d^'spnoea  may  be  overlooked ;  but  it  will  be 
generally  found,  on  careful  examination,  that  the  fever  is  slight, 
and  has  no  comparison  to  the  local  trouble  ;  the  paroxysms  recur 
at  uncertain  intervals,  and  they  often  terminate  very  rapidly. 
The  respiration  is  calm  and  undisturbed  between  the  paroxysms. 
The  dyspnoea  of  asthma  begins  gradually,  reaches  its  acme,  and 
then  declines ;  the  dyspnoea  of  heart  disease  is  generally  sudden 
and  due  to  exertion  ;  it  is  alarming,  and  when  it  has  subsided,  the 
patient  is  not  so  well  as  a  person  after  an  asthmatic  attack,  who 
will  be  able  to  go  about  his  duties  as  though  nothing  had  happened. 
A  patient  suflering  from  heart  disease  cannot  do  this.  An  adult 
wnth  a  delicate  heart,  or  a  child  with  mitral  disease,  cannot  run 
upstairs,  or  walk  up  a  hill  without  becoming  breathless  ;  but  it  is 
not  so  with  the  asthmatic,  for  when  the  paroxysm  is  ofl',  his  res- 
piration is  then  free  enough.  It  is  important  to  bear  these  dis- 
tinctions in  mind,  because  heart  disease  is  common  enough  in 
children.     If  asthma  or  heart  disease  be  complicated  with  emphy- 

*  Op.  cit.,  p.  621.  t  Berkart,  p.  83. 


398  DISEASES   OF   CHILDEEX. 

sema,  the  diagnosis  may  be  more  difficult.  A  certain  degree  of 
emphysema  probablj^  complicates  -all  asthma  of  long  standing  ; 
although  it  has  nothing  to  do  reallj'  with  the  cause  of  the  dis- 
order, being  rather  an  effect  of  it. 

Dj-spncea  of  an  intermittent  character,  it  should  be  remembered, 
is  also  associated  with  cerebral  disease,  but  the  history  would  point 
to  its  right  cause.  The  irritation  of  dentition  is  capable  of  caus- 
ino-  some  asthmatic  fits.  In  cases  of  enlarged  bronchial  glands 
pressing  upon  the  vagus  and  mediastinal  nerves,  attacks  of  dj'spnoea 
and  difiicult  breathing,  not  unlike  spasmodic  asthma,  maj^  arise, 
but  these  cases  ought  not  to  be  confounded  with  genuine  spas- 
modic or  bronchial  asthma,  which  solely  affects  the  structures  con- 
cerned in  the  paroxysm.  An  asthmatic  paroxysm  arising  from 
this  cause  would  be  likely  to  cease  as  the  child  grew  older  and  re- 
covered strength.'^ 

Prognosis. — This  is  greatly  determined  by  the  age  and  constitu- 
tion of  the  patient.  Dr.  Hyde  Salter  states  that  the  tendency  in 
young  subjects  is  almost  invariably  towards  recover}^;  and  that 
under  the  age  of  fifteen,  if  there  is  no  organic  disease,  we  may 
general!}'  predict  a  favorable  issue.  This  arises  in  a  great  measure 
from  the  power  possessed  by  young  persons  to  throw  off  disease  ; 
and  that  in  the  intervals  of  the  seizures  the  bronchial  congestion 
completely  passes  off,  and  the  capillaries  again  recover  their  lost 
tone.  Then,  too,  the  disease  does  not  last  so  long  as  is  generally 
the  rule  in  adults,  and  moreover  the  "  nervous  irritability  "  in  chil- 
dren, which  diminishes  as  they  grow  older,  also  favorably  influences 
the  prognosis. t  If  it  is  found  that  residence  in  some  favored  lo- 
cality keeps  off  the  attacks,  while  only  errors  in  diet  bring  them 
on,  then  the  patients  have  the  cure  in  their  own  hands.  But  if 
there  is  heart  disease  or  emphysema,  and  the  asthmatic  seizures 
have  recurred  so  frequently  as  to  induce  chronic  bronchitis  and 
impeded  breathing,  then  the  complication  is  serious.  A  recent 
writer  is  less  hopeful  of  a  favorable  termination.  He  saj's,  "  A 
complete  recovery  is  possible  only  in  chiklren  in  whom  the  disease 
is  produced  by  a  simple  hj-pertrophy  of  the  bronchial  glands,  as 
this  enlargement  occasionally  subsides  and  the  irritability  of  the 
lymphatic  system   also   diminishes   towards  puberty.     But  this 

*  See  Chap.  XXXIir,  On  Enlarj^ed  Broncluul  and  Mediastinal  Glands, 
t  On  Asthma,  \Hm,  p.  274. 


ON   ASTHMA.  399 

favorable  issue  is  very  rare,  and  there  are  few  instances  in  which 
cliildren  have  been  known  to  '  grow  out'  of  their  complaint."* 

The  presence  of  tubercular  or  renal  disease  will  increase  the 
gravity  of  the  prognosis.  In  these  cases  the  dyspnoea  is  perma- 
nent. It  may  be  here  mentioned,  however,  that  the  coexistence 
of  spasmodic  asthma  and  consumption  is  very  rare,  so  rare  that 
some  authorities  have  denied  it  altogether.  Dr.  Fuller  mentions 
three  cases,  and  I  have  seen  one.  "  The  utmost  that  can  be  truly 
stated  is  that  asthma  does  not  predispose  to  consumption,  nor 
tubercular  disease  to  spasmodic  asthma. "f 

It  is  extremely  rare  for  the  disease  to  terminate  fatally  in  a 
paroxysm.  Hyde  Salter  never  witnessed  a  paroxysm  prove  fatal. :{: 
It  most  usually  wears  out  the  patient  by  causing  obstruction  to 
the  circulation,  and  inducing  organic  disease  of  the  heart  and 
lungs. 

Pathology. — The  essential  cause  of  asthma  is  a  spasmodic  con- 
traction of  the  muscular  walls  of  the  bronchial  tubes ;  and  hence 
the  inspiration  becomes  difficult  because  enough  air  cannot  be 
drawn  into  the  pulmonary  tissue  to  properly  aerate  the  blood,  the 
forced  muscles  of  inspiration,  such  as  the  scapular  and  pectoral, 
are  therefore  brought  into  play,  and  the  diaphragm  is  more  or  less 
on  a  plane.  Most  competent  observers  now  admit  the  existence  of 
circular  muscular  fibres  in  the  smallest  bronchial  tubes,  and  they 
have  also  clearly  shown  that  irritation  of  the  par  vagum  will  ex- 
cite contraction  of  these  bronchial  muscles. 

A  pulmonary  neurosis  may  be  accompanied  by  moist  rhonchi  in 
the  lungs — an  excess  of  secretion  which  is  apt  to  lead  the  practi- 
tioner to  suppose  that  there  is  inflammation,  when  in  fact  there  is 
none.  This  condition  is  frequently  overlooked  in  nervous  and 
delicate  children ;  in  the  rickety  it  is  by  no  means  uncommon  to 
get  bronchial  sounds  of  a  persistent  character  following  slight 
catarrh.  The  secretion  from  the  mucous  membrane  is  consider- 
able, and  there  is  wheezing  and  hurried  respiration,  and  yet  there 
is  no  elevation  of  temperature  in  asthma.  It  is  not  an  inflamma- 
tory, but  a  truly  neurosal  disorder,  and  if  we  are  not  enlightened 
enough  to  recognize  this,  and  allow  the  idea  of  inflammation  in 
all  instances  to  take  possession  of  us,  we  shall  not  relieve  the  mor- 
bid state.     If  a  child  who  is  subject  to  asthma  takes  cold,  and 

*  On  Asthma,  by  J.  B.  Berkart,  M.D.,  1878,  p.  204. 

t  Op.  cit,  p.  370.  X  Op.  cit.,  p.  135. 


400  DISEASES    OF    CHILDREN. 

gets  an  attack  of  bronchitis,  the  bronchial  inflammation  may  act 
as  an  exciting  cause  in  producing  the  asthmatic  paroxysm,  but  it 
has  no  power  to  develop  it.  The  spasmodic  character  of  the  com- 
j)laint  is  very  strongly  shown  by  the  relief  which  the  inhalation 
of  sedatives  so  often  affords. 

The  degree  of  bronchitis  alone  would  not  produce  the  peculiar 
fit  of  asthma,  which  really  owes  its  origin  to  the  spasmodic  ele- 
ment. The  spasmodic  attack  is  chiefly  due  to  the  contraction  of 
the  muscular  coat  of  the  bronchial  tubes.  "  Even  then,  under  the 
catarrh,  which  overlies  the  nervous  element  so  as  to  mask  it,  the 
essence  of  the  disease  is  always  the  same,  and  its  nature  has  not 
changed."*  Still  it  must  be  conceded  that  repeated  asthmatic 
seizures  have  the  effect  of  thickening,  and  at  the  same  time  per- 
manently narrowing  the  bronchial  tubes,  by  throwing  upon  them 
an  extra  amoant  of  w^ork  to  discharge.  Hypertro]3hy  takes  place 
in  virtue  of  the  same  law  which  causes  muscles  to  become  larger 
w^hen  their  functions  are  increased.  "  A  certain  amount  then  of 
thickening,  and  a  certain  amount  of  contraction  of  the  bronchial 
tubes  is  fairly  to  be  assigned  to  asthma,  and  has  in  it  its  Sole  and 
suf&cient  cause."f 

Some  degree  of  emphysema  is  always  associated  with  asthma. 

Treatment. — The  rooms  in  which  these  patients  live  and  sleep 
should  be  large  and  airy,  with  high  ceilings  and  scanty  furniture. 
If  there  is  not  a  free  supj)ly  of  air  they  seem  choked,  and  cannot 
get  their  breath.  Air  is  what  they  want,  and  they  are  often  driven 
to  the  open  window  to  obtain  it,  unlike  patients  suffering  from 
any  other  pulmonary  complaint.  During  the  night  it  is  all-im- 
portant that  they  should  have  a  plentiful  supply  of  pure  air. 

The  next  point  to  attend  to  is  the  removal  of  the  neurosal  or 
spasmodic  element ;  the  presence  of  wheezing  and  catarrhal  sounds 
must  not  induce  us  to  overlook  this  important  matter,  for  if  we 
do,  and  the  asthma  goes  on  undetected,  we  shall  not  easily  subdue 
the  disease.  It  must  be  confessed  that  the  remedies  are  both 
numerous  and  uncertain  in  their  effects,  one  remedy  answering  in 
one  case  and  failing  to  afford  relief  in  another. 

If  there  is  much  secretion  and  congestion  attending  the  asth- 
matic paroxysm,  then  expectorants  will  be  needed  ;  but  if  there 
be  pure  spasm  then  a  residence  either  in  a  moist  or  a  pure  clear 


*  Trousseau,  Clin.  Med.,  vol.  i,  1867,  p.  623. 
t  Hyde  Salter,  op.  cit.,  p.  138. 


ox    ASTHMA.  401 

air  must  be  sought.  There  are,  however,  many  asthmatics  who 
can  breathe  well  in  the  close  confined  air  of  London,  bnt  cannot 
sleep  at  niglit  out  of  it.  These  peculiarities  are  most  difficult  to 
explain.  When  the  system  is  low  and  the  vessels  are  relaxed  and 
weak,  it  is  necessary  to  select  a  mild  climate,  so  that  the  bronchial 
mucous  membrane  may  not  be  irritated,  and  the  general  health 
improved. 

Nitrous  fumes  are  highly  useful  in  the  treatment  of  asthma 
•when  the  spasmodic  element  prevails,  and  there  is  no  bronchitis 
present.  The  fumes  act  as  an  antispasmodic  and  sedative  to  the 
irritated  bronchial  nerves.  "The  well-known  nitce-paper  is  best 
made  by  dissolving  four  ounces  of  nitrate  of  potash  in  a  pint  of 
hot  water,  and  in  this  should  be  soaked  a  porous  paper  of  the 
thickness  and  consistence  of  ordinary'  blotting-paper.  The  paper 
thus  made  will  be  strong,  fiercely-burning  paper,  and  should  be 
kept  in  a  stoppered  bottle.  When  used  it  must  be  burnt  fast  and 
furiously,  so  as  to  fill  the  room,  and  commonly  it  is  not  till  the 
atmosphere  is  quite  thick  with  nitrous  vapors  that  the  asthmatic 
gets  relief."'^ 

If  the  nitre-paper  fails.  Dr.  Thorowgood  recommends  that  the 
powdered  leaves  of  stramonium  or  dry  belladonna  leaves  be  sprin- 
kled on  it.f  Trousseau  advises  the  burning  of  stramonium  leaves. 
He  relates  the  case  of  a  child  who  was  always  relieved  by  this 
method  of  treatment.  The  advanta2:e  which  stramonium  smokino^ 
has  over  opium  is,  that  it  is  a  sedative,  but  not  a  narcotic.  Still, 
in  some  cases  it  utterly  fails. 

Belladonna  is  another  remedy  which  sometimes  acts  in  a  m.arvel- 
lous  manner.  It  has  a  similar  action  to  stramonium  in  diminish- 
ing the  contractility  of  the  bronchial  muscle,  and  in  allaying 
spasmodic  cough.  Children,  as  I  have  elsewhere  stated,  bear  bella- 
donna well,  and  therefore  the  dose  must  be  gradually  increased 
before  we  give  it  up  as  hopeless.:}:  The  remedy  may  be  sometimes 
advantageously  combined  with  bromide  of  potassium. 

Ipecacuanha^  in  emetic  doses,  sometimes  brings  unexpected  and 
inmiediate  relief;  it  lessens  nervous  irritability  by  its  action  as  a 
depressant ;  it  relaxes  the  bronchial  spasm,  and  if  there  be  much 
catarrh  clears  the  larger  bronchi  of  secretion,  and  in  this  way 
proves  beneficial.     Dr.  Salter  relates  the  ease  of  a  youth  who  had 

*  Lettsomian  Lectures,  On  Bronchial  Asthma,  1879,  p.  59. 
t  Op.  cit.,  p.  65.  X  S^s  Chapter  XXXII,  On  Whooping-cough. 

26 


402  DISEASES    OF    CHILDREX. 

asthma  from  infancy.  The  attacks  would  wake  him  about  four  or 
five  in  the  morning.  They  were  attended  with  severe  dj'spnoea 
and  wheezing,  and  he  was  obliged  to  get  out  of  bed.  In  half  an 
hour  after  taking  the  emetic  every  trace  of  asthma  had  disap- 
peared, and  he  would  then  sleep  like  an  infant,  and  have  no  return 
for  a  week.  The  dose  was  twenty  grains,  and  it  never  failed.* 
Its  action  was  that  of  a  depressant ;  it  produced  faintness  and 
nausea,  and  then  the  spasm  gave  way  and  relief  came,  before  it 
acted  as  an  emetic.  By  giving  the  remedy  at  the  commencement 
of  the  seizure  we  may  often  cut  it  short,  whereas  if  the  malady 
is  allowed  to  proceed,  and  the  spasm  and  bronchial  congestion 
have  become  thoroughly  established,  the  symptoms  are  longer  in 
yielding,  and  when  they  do  there  is  so  much  pulmonary  conges- 
tion and  dyspnoea  that  the  consequences  of  the  attack  are  long  and 
tedious. 

Tobacco  sometimes  acts  in  a  similar  manner,  but  it  has  a  ten 
dency  to  produce  more  deathly  collapse.  Antimony  has  also  a 
similar  action,  but  ipecacuanha  is  less  dangerous. 

Hydrate' of  chloral^  b\'  its  power  to  alhiy  spasm,  may  shorten  the 
asthraatic  paroxysm,  and  quiet  the  respiration.  It  is  sometimes 
given  with  the  effect  of  relieving  the  wheezing  and  sonorous 
rhouchi. 

Coffee  is  highlj^  recommended  by  Hyde  Salter.  He  sa^'S,  '"it 
relieves  asthma  in  two-thirds  of  the  cases  in  which  it  is  tried."  It 
should  be  given  strong,  in  small  quantities,  without  milk,  and  on 
an  empty  stomach. f  Thorowgood  gives  instances  of  great  success 
following  the  use  of  citrate  of  caffein,  in  doses  varying  from  one 
to  four  grains.  It  appears  to  calm  the  irritation  of  the  nerve 
centres,  to  allay  excitement,  and  to  promote  sleep.:}: 

Arsenic  has  been  found  very  serviceable  in  spasmodic  asthma. 
It  is  a  remedj^  which  appears  to  improve  the  breathing,  to  increase 
appetite  and  digestion,  and  to  act  as  a  general  tonic.  Mr.  Gaskoin, 
speaking  of  the  relation  between  psoriasis  and  asthma,  says,  that  a 
connection  existed  in  at  least  one-third  of  the  cases. §  "Where  the 
disease  is  complicated  with  eczema  or  psoriasis,  the  remedy  is 

*  However  young  the  patient,  tlie  dose  should  never  be  smaller  (Salter).  The 
powder  is  the  most  desirable  form. 

t  Op.  cit.,  p.  182.  X  Ibid.,  p.  72. 

§  On  the  relations  of  Asthma  to  Skin  Disease,  Royal  Med.-Ghir.  Soc,  March  10th, 
1874,  The  Lancet,  vol.  i,  p.  443,  1874. 


ox    ASTHMA.  403 

very  serviceable.  The  liquor  arpeniealis  may  be  given  in  two- 
minim  doses  three  times  a  day  after  food.  It  always  agrees  with 
children. 

Thorowgood  speaks  well  of  arsenical  preparations  in  spasmodic 
and  congestive  asthma.  He  recommends  gr.  ^\  of  arsenious  acid, 
or  liquor  arsenicalis  ^ij-nX"^^  three  times  a  day  after  food.* 

Tincture  of  nux  vomica  alone,  or  with  the  tincture  of  iron,  is 
also  useful  in  some  cases.  (Form.  58.)  The  syrup  of  the  hypo- 
phosphite  of  lime  and  iron  is  a  good  remedy.  Cod-liver  oil,  by 
improving  general  nutrition,  ought  to  be  given  in  suitable  cases, 
especially  if  the  patient  be  strumous  or  rickety. 

The  inhalation  of  the  iodide  of  ethyl,  in  ten-minim  doses  three 
times  a  day,  has  been  found  serviceable  in  some  cases  of  bronchial 
asthma,  according  to  Dr.  Thorowgood  and  other  writers;  but  in 
some  instances  it  causes  vertigo  and  dizziness.  It  is  antispasmodic, 
and  relieves  congestion  at  the  same  time. 

The  inhalation  of  chloroform  has  also  been  employed  with  great 
success  in  arresting  a  paroxysm.  Where  the  bronchial  spasm  is 
severe,  and  the  agony  is  distressing,  there  can  be  uo  objection  to 
trying  it  if  other  remedies  fail.  The  inhalation  should  be  proceeded 
with  slowly  and  cautioush",  for  it  is  to  be  noted  that  the  S23asm 
may  yield  entirely  without  insensibility  being  produced.  Tempo- 
rary relief  may  also  be  sometimes  obtained  by  the  judicious  use  of 
morphia,  ether,  lobelia,  or  ammonia. 

According  to  Salter  opium  never  does  good  in  asthma.  It  fre- 
quently does  harm  by  narcotizing  and  producing  sleep,  for  the 
heavier  and  more  drowsy  the  patient  becomes  the  more  likely  is 
the  asthmatic  paroxj'sm  to  supervene. 

Dr.  Berkart  speaks  highly  of  the  use  of  pilocarpin  in  the 
asthmatic  paroxysm.  He  says  that  it  attracts  to  the  skin  and 
salivary  glands  a  large  volume  of  blood,  and  so  relieves  the  con- 
gested internal  organs  by  the  copious  perspiration  and  salivation 
which  it  induces.  \Yhere  the  cardiac  muscles  are  weak,  or  the 
heart  is  in  a  state  of  fatty  degeneration,  alarming  symptoms  may 
ensue,  but  the  subcutaneous  injection  of  gr.  y^^  o^*  S^-  eV  ^^  atro- 
pia  soon  restores  the  balance.  Ten  drops  of  a  two  per  cent,  solu- 
tion of  pilocarpin  should  be  injected  for  an  adult,  and  a  less  quan- 
tity for  a  child.  The  patient  should  assume  a  recumbent  posture 
(which  the  speedy  relief  afibrded  enables  him  to  do),  and  the 

*  Op.  cit.,  p.  69. 


404  DISEASES    OF    CHILDRElSr. 

effects  of  the  remedy  watched  till  they  have  passed  away.  "  Pilo- 
carpiu  is  more  suitable  in  the  treatment  of  the  younger  asthmat- 
ics, but  is  by  no  means  contraiudicated  in  patients  of  more  ad- 
vanced age."* 

Spray  inhalations  of  carbolic  acid,  ipecacuanha,  benzoin,  crea- 
sote,  etc.,  are  all  useful  in  certain  cases;  but  in  children  they  are 
not  very  easy  of  application. 

Diet  is  of  the  utmost  importance.  It  should  be  of  the  simplest 
description,  as  roast  or  boiled  fresh  meat,  chicken,  light  pudding, 
etc.,  given  at  regular  intervals.  If  the  food  be  indigestible,  or  too 
much  be  taken  at  one  time,  then  it  is  apt  to  disorder  the  stomach, 
and  to  bring  on  a  paroxysm  of  dyspnoea.  It  is,  therefore,  impor- 
tant to  select  such  a  diet  for  the  child  that  whilst  it  appeases  its 
appetite  it  shall  contain  the  necessary  nutritious  elements.  If 
during  digestion  the  food  taken  undergoes  fermentation,  and  pro- 
duces distension  and  fulness,  the  breathing  will  be  deranged. 

A  sparing  quantity  of  fluid  should  be  taken,  and  beer  and  stimu- 
lants ought  to  be  avoided.  The  bowels  should  be  kept  free  by 
gentle  aperients,  as  a  little  sulphate  of  magnesia,  or  compound 
liquorice  powder;  and  if  there  are  worms  in  the  intestinal  canal, 
the  proper  remedies  should  be  selected  for  their  expulsion. 

Gentle  exercise  in  the  open  air  is  most  essential  when  the 
weather  is  mild.  It  brings  the  muscles  into  better  working  order, 
improves  the  failing  appetite,  stimulates  the  functions  of  the  skin, 
by  which  morbid  products  are  removed  from  the  body,  and  in  this 
way,  as  the  general  strength  is  built  up,  so  the  child  may  possibly 
grow  out  of  its  disorder. 

An  occasional  warm  bath  at  bedtime  will  prove  of  great  utility, 
by  relieving  the  congestion  of  the  lungs  and  bronchi,  and  in  this 
way  will  equalize  the  cutaneous  and  respiratory  functions.  Tid- 
man's  sea-salt  may  be  added  to  the  morning  bath  if  the  child  is 
in  a  fitting  state  for  it,  and  the  weather  is  warm  enough.  These 
baths  act  as  tonics,  and  are  very  useful  in  strumous  and  rickety 
cases. 

"In  feeble  children,  especially  those  whose  thorax  had  been 
crippled  by  rickets,  gentle  gymnastics  (Swedish)  greatly  assist 
the  development  of  the  lungs.  Athletic  sports,  if  not  carried  to 
exhaustion,  are  still  more  useful."! 

*  Brit.  Med.  Journ.,  1880,  vol.  i,  p.  918. 
f  Berkart,  op.  cit.,  p.  221. 


EMPHYSEMA.  405 


CHAPTER   XXXV. 

EMPHYSEMA, 

Two  Vakieties  generally  described:  1.  The  vesicular.  2.  The  interlobular. — 
Pathology,  General  Symptoms,  and  Physical  Signs.  Causes  and  Conse- 
quences. Treatment:  Iron — Strychnia — Use  of  emetics  and  expectorants  where 
bronchitis  or  asthma  are  present — Active  apaients  to  relieve  conc/estion  of  intei^al 
organs — Sedatives  and  Sedative  inhalations  to  allay  cough — If  emaciation  or  profuse 
expectoration  arc  present,  cod-liver  oil  or  malt  extract — Regulation  in  diet — Gentle 
exercise — Change  of  air. 

"We  meet  witli  two  forms  of  this  disease,  the  vesicular  and  the 
interlobular ;  in  the  former  condition  a  number  of  air-cells  are 
dilated,  and  their  walls  being  ruptured  and  torn  they  become 
merged  into  one,  or  the  alveolar  spaces  may  be  simply  distended 
through  a  loss  of  elasticity,  and  their  vessels  atrophied  and  de- 
stroj'ed  ;  in  the  latter  condition  the  air-vesicles  are  ruptured,  and 
air  escapes  into  the  intercellular  tissue  of  the  lungs  and  causes 
distension.  In  vesicular  emphysema,  which  is  by  far  the  most  fre- 
quent variety,  the  lungs  are  increased  in  size,  while  their  elasticity 
is  destroj^ed,  so  that  when  the  chest  is  opened  their  anterior  bor- 
ders are  in  close  contact,  and  they  do  not  collapse.  The  surface  of 
the  lungs  is  irregularly  elevated  from  the  dilatation  of  the  air- 
cells,  but  there  is  no  escape  of  air  into  the  connective  tissue.  In 
this  variety  a  few  air-sacs  may  be  involved,  the  whole  of  a  lobule, 
or  even  the  entire  lung.  The  apices  and  margins  of  the  base  of  the 
lungs  are  particularly  liable  to  be  affected.  The  lung-tissue  has 
lost  its  crepitant  feeling  to  the  touch,  it  pits  on  pressure,  and  is 
doughy,  pale,  and  bloodless ;  the  borders  of  the  lungs  come  for- 
ward, covering  the  heart,  and  the  liver  is  depressed,  whilst  the 
configuration  of  the  thorax  is  altered,  becoming  short,  deep,  and 
rounded. 

Emphysema  in  its  acute  form  is  not  an  infrequent  disease  among 
children,  and  especially  those  who  are  the  subjects  of  rickets  and 
asthma;  in  the  chronic  form  it  is  more  common  in  adults.  In 
children  who  have  died  of  acute  bronchitis  or  pneumonia,  portions 
of  the  lung  will  often  be  noticed  to  be  emphysematous.  This, 
however,  is  a  long  and  complicated  subject,  and  the  reader  will 
find  the  pathology  fully  discussed  in  the  ordinary  textbooks. 

Interlobular  Emphysema. — In  this  variet}'-  the  connective  tissue 
which  binds  the  lobules  together  is  infiltrated  with  air,  w^hich  es- 


40G  DISEASES    OF    CHILDREN. 

capes  into  it  and  beneatli  the  pleura,  in  consequence  of  the  air- 
vesicles  having  ruptured.  "  I  have  never  seen  it  as  an  independent 
affection,  but  in  almost  every  case  where  there  has  been  extensive 
vesicular  emphysema  I  have  found  the  interlobular  kind  existing 
to  a  greater  or  less  extent.  It  is  often  very  partial,  and  seems  to 
have  little  disposition  to  spread."*  Some  other  writers  consider 
that  it  is  verj^  rarely  connected  with  vesicular  emphysema.f  Cases, 
in  which  the  pleura  is  raised  from  the  surface  of  the  lung  by  em- 
physema are  most  frequently  met  with  in  whooping-cough,  and  in 
one  case  under  my  care:|:  the  apices  of  the  lungs  were  much  involved, . 
producing  marked  swelling  of  the  neck  from  the  extravasation  of 
air  into  the  cellular  tissue.  In  this  form  the  air-vesicles  are  rounded, 
prominent,  and  movable,  and  can  be  squeezed  from  one  place  to 
another  between  the  lobules,  and  it  may  even  lead  to  general  em- 
physema. This  variety  is  comparatively  rare  in  children.  Whoop- 
ing-cough is  its  most  frequent  cause. 

Vesicular  Emphysema — Pathology. — There  can  be  no  doubt  that 
the  morbid  changes  may  be  produced  by  mechanical  causes,  as  in 
Avhooping-cough  and  bronchitis,  which  causes  stretching  and  dimi- 
nution in  the  elasticity  of  the  air-sacs,  and  this  without  any  mor- 
bid change  in  the  lung-tissue  itself;  still  it  must  be  admitted  that 
the  disease  sometimes  creeps  on  in  children  who  have  not  suffered 
from  these  affections,  or  any  violent  cough,  as  we  shall  hereafter 
see.  The  air-sacs  become  stretched  and  enlarged,  and  finally  the 
elastic  fibres  give  way,  leading  to  jDerforation  and  rupture.  Fatty 
matter  has  been  found  in  the  emphysematous  portions  of  the  lung, 
and  fatty  degeneration  assists  in  the  rupture  of  the  air-cells.  In 
some  children  it  is  the  result  of  pulmonary  catarrh,  but  cases  occur 
in  which  it  appears  to  arise  spontaneously  without  any  hereditary 
influence,  and  such  instances  as  these  are  chiefly  met  with  in  stru- 
mous and  tubercular  subjects.  In  some  children  it  appears  to  be 
congenital,  and  in  two  cases  which  came  under  my  care  in  1876 
and  1877,  no  other  cause  could  be  assigned. §  It  often  arises  in 
connection  with  pulmonary  collapse  and  bronchitis  in  children  from 
forcible  inspiration,  and  the  strain  put  upon  the  distended  air- 

*  Diseases  of  the  Cliest,  by  A.  T.  H.  Waters,  IS?"),  p.  113. 

t  Diseases  of  the  Lungs,  by  W.  H.  Walslie,  M.D.,  1854,  p.  489. 

X  See  Chap.  XXX II,  On  Whooping-cough. 

^.  Of  43  emphysematous  persons,  the  hereditary  tendency  was  well  marked  in  per- 
sons from  7  to  20  years  of  age,  the  number  being  five,  and  all  predisposed  to  the  dis- 
ease in  either  parent. — Fuller,  On  Diseases  of  the  Lungs,  p.  339. 


EMPHYSEMA.  407 

vesicles  by  coiigliiiig.  It  is  not  commonly  associated  with  pneu- 
monia, and  still  rarer  with  tubercle  or  phthisis ;  but  in  nearly 
every  case  it  may  be  stated  that  there  is  pre-existing  disease  in 
some  of  the  vesicles  or  lobules  of  the  lungs.  The  bronchial  tubes 
are  generally  in  a  state  of  chronic  intlammation,  and  pleuritic  ad- 
hesions are  not  rare.  The  disease  tends  to  produce  hj'pertrophy 
of  the  right  heart  and  cerebral  congestion. 

Si/mpioms. — The  chief  symptoms  are  shortness  of  breath  and 
dyspnoea,  increased  by  walking  fast,  ascending  a  hill,  or  going  up- 
stairs. At  first  this  is  only  felt  on  exertion,  but  as  the  disease 
advances  the  breathing  becomes  accelerated,  and  even  panting 
when  the  patient  is  sitting  still.  An  attack  of  bronchial  irrita- 
tion, or  indigestion,  will  aggravate  the  condition,  particularly  if 
there  is  flatulence,  which,  however,  is  more  frequent  in  adults.  In 
many  respects  the  symptoms,  according  to  my  experience,  are  far 
less  urgent  in  children  than  in  adults,  and  the  fits  of  orthopncea 
and  violent  palpitation,  which  are  so  common  in  the  latter,  are 
not  usual  among  the  former  in  the  most  advanced  stages  of  the 
disease.  The  sputa  are  bronchial,  and  sometimes  there  is  a  little 
blood,  from  the  rupture  of  small  bloodvessels  in  the  distended 
lung-tissue.  The  face  is  dusky  and  anxious,  and  in  old-standing 
cases,  it  has  a  cyanotic  tint ;  the  nostrils  are  dilated,  the  voice  is 
weak,  and  the  cough  feeble ;  the  pulse  is  weak,  and  like  the 
respiration,  usually  slow;  the  hands  feel  cold,  and  the  fingers 
have  a  bluish  tint.  Headache  and  drowsiness  are  common.  In 
some  cases  emaciation  is  considerable ;  the  abdomen  is  large,  and 
as  the  disease  is  confirmed  the  liver  and  spleen  become  increased 
in  size.  If  dropsy  occur  there  is  generally  tricuspid  regurgitation. 
In  recent  cases  complicated  with  whooping-cough,  the  lips  are 
puffed  and  venous,  the  conjunctivae  are  watery  and  injected,  and 
the  nose  loses  its  outline  from  pufliness  and  infiltration  of  the  sub- 
cutaneous cellular  tissue  ;  the  clavicles  are  elevated,  and  depressions 
may  be  noted  above  them  in  some  cases.  These  spaces  are  some- 
times completely  obliterated,  or  they  are  even  prominent  and 
puffy,  in  consequence  of  the  emphysematous  apices  of  the  lungs 
forcing  their  way  upwards  from  the  thoracic  cavity.  The  whole 
thorax  is  elevated  and  increased  in  size  at  its  upper  part  (barrel- 
shaped),  the  ribs  lose  their  obliquity,  and  their  anterior  extremi- 
ties are  drawn  upwards.  The  intercostal  spaces  are  widened,  and 
the  spine  curved  with  the  concavity  forward.     In   the  case   tO' 


408  DISEASES    OF    CHILDEEX. 

which  allusion  is  made  further  on,  the  capacity  of  the  lower  part 
of  the  chest  was  much  diminished. 

The  complaint  is  increased  in  the  winter  and  spring  months, 
and  decreases  in  summer  and  mild  weather.  In  those  cases  which 
are  owing  to  permanent  organic  change,  dry  bracing  weather 
always  relieves  the  respiration. 

The  resjMration  is  characteristic.  The  child,  like  the  adult, 
leans  forward  in  bed  with  its  hands  folded,  the  muscles  of  the 
neck,  as  the  scaleni  and  sterno-cleido-mastoidei,  being  brought 
into  powerful  action,  and  the  shoulders  rounded.  The  upper 
part  of  the  chest  is  nearly  fixed,  for  the  lungs,  having  already 
expanded  to  the  utmost,  are  scarcely  affected  by  inspiration.  The 
lower  portion  of  the  thorax  is  drawn  in,  and  the  diaphragm  in 
these  cases  appears  passive,  and  the  abdomen  flat,  or  even  concave. 
The  respiration  varies,  however,  the  thorax,  in  some  cases,  being 
distinctly  raised  and  elevated,  and  the  abdominal  muscles  forcibly 
expanding.  The  inspiration  is  short  and  hurried,  from  the  dimin- 
ished expansion  of  the  chest,  and  the  expiration  is  wheezing  and 
prolonged,  because  the  elasticity  of  the  lungs  is  lessened.  In  con- 
versation the  child  waits  to  get  breath  if  its  answers  are  required 
quickly,  and  spasmodic  fits  of  coughing  are  common  if  the  bron- 
chial tubes  are  loaded  with  mucus.  The  character  of  the  breath- 
ing is  one  of  the  most  significant  symptoms  of  the  complaint. 

A  physical  examination  of  the  chest  reveals  bulging  of  the 
infraclavicular,  mammary,  and  entire  sternal  regions.  The  cir- 
cumference of  the  thorax  is  increased,  not  only  because  the  ribs 
are  more  horizontal,  and  the  intercostal  spaces  widened,  but  the 
lungs  themselves  are  larger,  from  overdistension  of  the  air-vesi- 
cles, and  the  spine  is  curved  forwards,  as  we  have  before  seen. 
The  resonance  is  so  increased  as  sometimes  to  amount  to  tympan- 
ites over  the  whole  thorax,  the  note  elicited  on  percussion  being 
much  exaggerated  in  clearness  and  fulness,  especially  along  the 
line  of  the  sternum,  where  the  borders  of  the  lung  approximate. 
This  clear  percussion-sound  arises  from  there  being  more  air 
within  the  chest,  and  inspiration  does  not,  as  in  healthy  lungs, 
aflf'cct  it  ;  nor  is  it  diminished  by  any  forced  expiratory  effort. 
The  res[»iration  is  weak,  rarely  raised  in  pitch,  but  it  may  be  con- 
siderably altered  in  quality,  and  sometimes  be  heard  loud  and 
superficial,  or  mixed  with  sibilant  rhonchus. 

AVlien  the  lungs  are  much  involved  the  heart  is  pushed  back- 


EMPHYSEMA.  409 

wards  and  downwards  towards  the  median  line,  and  the  whole 
cardiac  region  is  resonant,  notwithstanding  a  great  amount  of 
hypertrophy  of  the  right  heart.  Epigastric  pulsation  is  often  ob- 
servable. If  the  heart  is  simply  thrown  backwards  behind  the 
overlaping  lung  the  sounds  are  weaker  and  more  distant.  When 
in  long-standing  cases  the  right  heart  is  unable  to  empty  itself,  the 
auriculo-veutricular  valve  becomes  damaged,  and  being  unable  any 
longer  to  fully  contract  on  its  contents,  the  walls  of  the  ventricle 
yield  and  become  dilated,  so  that  congestion  of  all  the  internal 
organs  takes  place  gradually,  and  this  quantity  of  blood  being 
thrown  back  on  the  general  circulation,  venous  congestion  is  some- 
times followed  by  ascites  and  anasarca.     But  this  is  rare. 

In  children,  where  the  disease  has  been  of  any  continuance,  there 
is  often  marked  antemia  and  pallor  of  the  surface ;  the}-  lose  flesh 
and  strength,  and  become  sallow  and  cachectic  as  the  complaint 
continues,  or  there  is  a  fixed  venous  abrupt  color  on  the  cheeks,  as 
we  have  before  remarked.  It  is  in  such  cases  as  these  that  we 
often  notice  that  the  jugular  veins  are  swollen,  the  neck  broad, 
and  the  shoulders  elevated. 

Emphysema  and  tuberculosis  sometimes  exist  together,  but  in 
my  experience  the  alliance  is  rare,  and  no  well-marked  case  has 
come  under  ray  notice  for  years.  Dr.  Theodore  AVilliams,  how- 
ever, informs  me  that  it  is  common  enough  at  the  Brompton  Hos- 
pital. 

One  of  the  most  marked  cases  of  emphysema  I  have  seen,  was 
that  of  a  girl,  jet.  11,  who  was  of  short  stature  arid  very  thickly 
set ;  her  tildfe  were  both  curved  anteriorly  at  the  lower  third,  the 
head  was  large  and  the  neck  very  short.  Her  face  had  a  distressed 
and  sad  appearance  from  cardiac  trouble,  and  the  thorax  presented 
the  following  condition :  It  was  deep  in  its  antero-posterior  diam- 
eter, and  much  rounded  over,  and  the  intercostal  spaces  in  this 
situation  were  completely  obliterated.  The  elevation  commenced 
immediately  and  somewhat  abruptly  below  the  clavicles,  and  was 
rounded  to  the  nipple  on  the  right  side,  whence  the  ribs  sank  in  ; 
on  the  left  side  it  was  much  more  bulging  and  prominent  over  the 
whole  cardiac  region,  and,  in  consequence  of  the  hypertrophied  and 
strong  action  of  the  heart,  the  ribs  below  the  nipple  w^ere  not  re- 
tracted as  on  the  other  side.  The  upper  portion  of  the  lungs,  being 
in  a  state  of  emphysema,  had  forced  the  heart  downwards,  as  we 
sometimes  see  in  aortic  regurgitation,  and  had  produced  collapse 


410  DISEASES    OF    CHILDREX. 

in  the  lower  lobes.  The  apex  beat,  instead  of  being  limited  to  the 
area  of  health,  was  diffused  over  a  large  space  ;  long-continued 
congestion  had  caused  enlargement  of  the  liver,  so  that  its  edge 
could  be  felt  in  the  epigastrium.  The  breathing  was  diaphrag- 
matic, the  upper  part  of  the  sternum  almost  fixed  in  respiration, 
though  the  clavicles  and  shoulders  rose  with  each  inspiration,  a 
slight  cup-shaped  dej^ressiou  being  noticeable  above  the  clavicle. 
The  whole  thorax  rose  at  once,  instead  of  the  slow  dilatation  of 
the  chest-walls,  as  in  health.  The  sinking  in  of  the  epigastrium, 
and  the  drawing  inwards  of  the  lower  ribs  during  inspiration, 
proved  that  the  entrance  of  air  to  the  whole  pulmonary  tissue  was 
interfered  with,  and  this  sometimes  happens  in  bronchitis,  causing 
collapse  of  the  lungs.  Posteriorly  the  chest  was  much  rounded  and 
the  sternum  arched,  and  although  the  child  was  not  stout,  the  in- 
ternal or  posterior  border  of  the  scapulae  could  scarcely  be  seen.* 
Dr.  Steiner  saj's:  "The  capacity  of  the  chest  is  increased,  though 
it  does  not  present  the  peculiar  barrel-shaped  enlargement,  which 
is  the  result  of  emphj-sema  in  adults. "f  l^o  better  instance  to  the 
contrarj-  could  have  been  furnished  than  this  case. 

There  was  a  difference  in  the  percussion,  and  in  the  character 
of  the  breathing'  over  the  rio;lit  back  ;  the  note  was  more  resonant 
over  the  greater  part  of  the  lung,  and  the  breathing  weaker,  the 
inspiration  being  very  short  and  deficient,  and  the  expiration  pro- 
longed. Over  the  left  lung,  the  inspiration  was  longer,  but  not 
so  much  so  as  the  expiration,  which  was  musical  and  wheezing, 
and  the  lung  was  less  resonant  throughout.  In  the  right  axilla, 
and  as  low  as  the  line  of  the  fourth  rib,  a  little  faint  breathing  was 
heard,  but  none  over  the  retracted  ribs  or  the  infra-axillary  region 
indicating  collapse.  The  pulse  was  96,  respirations  32,  temperature 
normal ;  no  expectoration.  The  face  was  not  swelled,  but  the 
cheeks  had  a  deep  crimson  flush,  and  the  lips  were  dusky.  From 
time  to  time,  in  consequence  of  the  gravity  of  the  heart  affection, 
there  was  great  headache,  owing  to  f)assive  hyperremia  of  the 
brain  ;  the  forehead  was  hot,  and  ached  for  days  together ;  the 
jugular  veins  were  swollen,  the  temporal  vessels  were  full  and 
throbbing,  and  the  child  did  not  know  where  to  lay  her  head  for 
ease.     The  whole  cardiac  region  was  resonant,  from  the  edges  of 

*  Heart  Disease  in  Children,  connected  with  Valvular  Disease,  and  with  Thoracic 
Deformity,  Medical  Society  Proceedings,  vol.  iv,  p.  196,  and  Medical  Press  and  Cir- 
cular. May  7th-14th,  1879. 

f  Dhbiiiyda  of  Children,  translated  by  Lawson  Tait,  F.E.C.S.,  1874,  p.  157. 


EMPHYSEMA.  411 

the  lungs  being  emphysematons  and  overlapping  the  heart.  It 
was  somewhat  remarkable  in  this  case  that  there  could  exist  such 
a  degree  of  heart  disease  (tricuspid  and  mitral)  with  obstruction 
to  the  circulation  through  the  lungs  without  any  sign  of  dropsy, 
or  turbid  urine,  the  latter  secretion  being  at  all  times  free  and 
healthy.*  Indeed,  in  children  I  have  rarely  met  with  ascites  or 
anasarca,  but  we  know  the  disease,  especially  with  heart  affection, 
is  prone  to  produce  these  complications. 

Emphysema  is  irrecoverable  when  complicated  with  organic 
disease  of  the  heart  or  asthma ;  but  when  it  occurs  as  the  accom- 
paniment of  whooping-cough,  it  will  gradually  pass  away  with  the 
disorder,  and  the  child  may  grow  up  without  any  sign  of  ever 
having  suffered  from  it. 

Treatment. — The  pathology  of  the  disease  proves  that  the  rup- 
tured lung-tissue  is  incapable  of  repair,  but  in  slight  and  recent 
cases  we  may  do  much  to  arrest  further  destructive  changes.  Con- 
stitutional remedies  are  chiefly  to  be  relied  upon  in  these  cases,  for 
if  we  cannot  again  restore  the  elasticity  of  the  walls  of  the  air-cells 
to  their  normal  state,  we  may  prevent,  or  at  least  indefinitely 
retard,  degeneration  in  the  structure  of  the  lungs.  If  there  is  an 
absence  of  renal  disease,  and  the  heart  is  feeble  in  its  action,  we 
must  select  such  remedies  as  will  strengthen  it,  and  improve  the 
quality  of  the  blood  at  the  same  time.  In  the  shapeof  drugs,  iron 
is  one  of  the  best  remedies  for  improving  the  cachexia  which  is  so 
often  present.  The  tincture  of  the  perchloride  is  my  favorite  form. 
Dr.  Waters  speaks  well  of  the  ethereal  tincture  of  the  acetate. 
Strychnia  has  been  employed  to  increase  the  tone  of  the  muscular 
fibre  in  the  relaxed  bronchial  tubes,  but  no  positive  benefit  has  ever 
followed  its  use,  nor  has  electricity  done  any  good  to  the  damaged 
pulmonary  tissue. 

If  bronchitis  is  an  accompaniment,  and  the  disease  is  acute,  it 
will  demand  for  the  time  being  our  chief  consideration,  but  the 
remedies  should  not  be  too  depressing.  An  emetic  of  sulphate  of 
zinc  is  sometimes  useful  by  relieving  the  pulmonary  congestion 

*  In  confirmed  cases  of  vesicular  emphysema  renal  congestion  takes  place,  when 
albumen  and  sometimes  blood  are  present  in  the  urine.  It  is  in  such  cases  that  the 
secretion  is  often  high-colored,  and  throws  down  copious  urates  on  standing.  At  other 
times,  in  equally  severe  cases,  the  urine  may  be  abundant  and  clear,  and  of  low  specific 
gravity.  When  there  is  a  large  and  persistent  amount  of  albumen,  and  the  circulation 
through  the  lungs  is  not  much  impeded,  there  is  suspicion  of  organic  disease  of  the 
kidneys. 


412  DISEASES    OF    CHILDREN". 

and  overloaded  digestive  organs.  Where  the  mucous  membrane 
is  dry,  and  the  breathing  short,  ipecacuanha  and  the  solution  of 
the  acetate  of  ammonia  may  be  employed,  with  or  without  iodide 
of  potassium  or  chloride  of  ammonium,  to  favor  secretion.  If 
there  is  difiiculty  in  expectoration,  and  of  ridding  the  bronchial 
tubes  of  mucus,  carbonate  of  ammonia,  squill,  senega,  and  wine 
will  be  needed.  After  this  stage  has  passed  awaj^  iron  may  again 
be  given. 

For  the  asthma,  heart  disease,  and  dropsy  accompanying  emphj^- 
sema,  the  treatment  must  be  directed  in  accordance  with  the  pre- 
vailing symptoms. 

Where  there  is  passive  hypertemia  of  the  chief  internal  organs, 
as  the  liver,  spleen,  and  kidneys,  a  scanty  diet  and  free  purgation 
will  be  occasionally  needed.  ISTo  remedies  tend  so  efiectually  to 
relieve  the  shortness  of  breath  as  a  grain  of  calomel  now  and  then, 
followed  by  a  seidlitz  powder,  or  some  saline  aperient.  After  this 
a  gentle  effect  on  the  liver  may  be  kept  up  by  taraxacum,  with  a 
few  grains  of  bicarbonate  of  soda,  or  the  nitro-muriactic  acid  with 
taraxacum,  or  calumba  (Form.  20-42).  Quinine  and  small  doses 
of  strychnine,  to  improve  appetite  and  digestion,  are  to  be  recom- 
mended. 

Where  the  brain  is  overloaded  with  blood  from  passive  conges- 
tion, a  few  leeches  to  the  temples  and  cold  to  the  head,  will  be 
required  before  relief  follows. 

Sedative  remedies  to  relieve  cough,  if  at  all  violent,  must  be 
given  (Form.  65-74) ;  they  obviate  in  some  degree  the  congestion 
of  the  lungs  which  is  sure  to  follow  continued  paroxj-sras,  and  pre- 
vent the  patient  from  obtaining  rest.  Sedative  inhalations  are 
also  useful.  The  required  quantity  of  chloroform,  or  nitrite  of 
amyl,  conium,  or  hops,  is  to  be  put  on  a  piece  of  sponge  and  in- 
haled through  a  convenient  apparatus,  as  the  steam  of  hot  water 
passes  through  it,  or  the  medicated  fluid  may  be  put  into  a  pint 
of  water  at  150°,  and  the  inhalation  be  continued  for  about  ten 
minutes.  The  patient  should  inhale  before  meals,  and  should  not 
venture  out  of  doors  for  some  time  afterwards.  The  Electric  In- 
haler, made  by  Alaw,  at  the  suggestion  of  Dr.  Alorell  Mackenzie, 
is  very  convenient.* 

If  the  bronchitis  and  catarrh  when  present  be  attended  with 
profuse  expectoration,  and  the  child  is  losing  flesh,  quinine,  iron, 

*  The  Pharmacopoeia  of  t]ie  llosijital  for  Di-seases  of  tlie  Throat,  1872,  p.  07. 


BEONCHITIS.  4 1 3 

the  mineral  acids,  and  cod-liver  oil  or  malt  extract,  will  be  bene- 
ficial. 

Blisters  are  not  required  for  children,  but  liniments,  turpentine 
fomentations,  and  mustard  poultices  may  be  needed  to  relieve 
congestion  of  the  stomach  or  lungs. 

The  diet  in  all  chronic  cases  must  be  generous  and  carefully 
regulated,  the  food  being  nutritious  and  given  in  small  quantities 
80  as  not  to  overload  the  digestive  organs  and  cause  flatulence, 
which  distresses  the  heart  by  interfering  with  the  action  of  the 
lungs  and  the  descent  of  the  diaphragm. 

Gentle  and  never  violent  exercise  should  be  resorted  to,  care 
being  taken  to  avoid  fatigue  and  to  calm  the  nervous  apprehen- 
sions of  the  sufferer. 

Change  of  air  often  proves  of  great  benefit. 


CHAPTER   XXXYI. 

BRONCHITIS. 


Two  Varieties:  1.  The  acute — 2.  The  chronic — Exposure  to  cold  a  common  exciting 
cause  of  the  acute — Irritation  of  dust  and.  noxious  vapors — Over-suckling — Bronchitis 
■  from  tubercular,  renal,  and  heart  diseases — Often  an  accompaniment  of  measles  and 
whooping-cough — Mortality  of  bronchitis.  Symptoms  of  Acute  Bronchitis  {Cap- 
illary bronchitis).  Physical  and  General  :  Pulse — Respiration — Temperature — 
State  of  the  pulmonary  mucous  membrane — Death  by  exhaustion,  convulsions,  or  coma- 
Chief  indications  denoting  danger — Chronic  bronchitis  may  be  a  sequel  of  the  acute  form, 
or  be  associated  with  renal  disease  or  valvular  disease  of  the  heart — Its  symptoms  and 
complications — Morbid  changes  found  in  the  lungs  infcdal  cases — Collapse  of  lung,  how 
produced — Frequency  in  children — Expansion  and  dilatation  of  bronchi — Sequelje  : 
Emphysema — Congestion  of  liver — Disease  of  heart — Dropsy — Pathology  of  acute  and 
chronic  bronchitis.  Treatment  or  the  Acute  Variety  in  Different  Stages  : 
Depletory  measures — Tartar  emetic — Diaphoretics — Alkalies  in  combination  with  a 
mercurial — Stimulating  expectorants — Saline  aperients — Henbane — Dangers  of  opium 
by  lessening  secretion,  and  of  chloral  by  depressing  cardiac  ganglia — Bt'omide  of  potas- 
sium—  Value  of  tonics — Beef  tea — Milk — Stimulants — Failure  of  right  heart.  Treat- 
ment OF  Chronic  Bronchitis:  Conium — Dover' s powder — Squill — Ipecacuanha — 
Emetics — Syrup  of  iodide  of  iron — Cod-liver  oil — Mineral  acids — Quinine — Change 
of  ah —  Warm  clothing. 

Two  varieties  of  bronchitis  are  described,  the  acute  and  chronic. 
The  acute  frequently  follows  on  ordinary  catarrh  or  cold,  which 
for  some  days  haa  seized  upon  the  young  patient  with  the  well- 


414  DISEASES   OF   CHILDREN. 

kno'^n  symptoms  previously  described, — running  from  tlie  eyes 
and  nostrils,  frontal  headache,  loss  of  appetite,  sore  throat,  and 
febrile  disturbance.  At  the  end  of  a  few  days  (for  the  time  can- 
not always  be  definitely  stated)  the  irritation  may  have  extended 
to  the  bronchial  mucous  membrane,  and  the  child  gradually  get- 
ting; worse  is  unable  to  leave  his  bed. 

Among  the  chief  causes  which  invite  this  aflection  are  cold  and 
sudden  changes  of  temperature  (hence  its  prevalence  in  the  spring 
and  winter  months),  insufficient  clothing,  the  irritation  of  dust 
and  noxious  vapors  ;  debility  from  prolonged  suckling,  and  what- 
ever circumstances  tend  to  reduce  the  tone  of  the  body,  rendering 
it  unable  to  resist  disease  of  any  kind,  more  particularly  that 
which  is  so  prone  to  seize  upon  the  bronchial  membrane  at  an 
early  period  of  life. 

Bronchitis  in  children  ma}^  arise  from  hypertrophy  and  valvular 
diseases  of  the  heart,  which  induce  local  congestion  and  disturb 
the  balance  of  the  circulation.  It  occurs  in  tuberculosis,  albu- 
minuria, and  some  other  disordered  states  of  the  blood,  and  it 
accompmies  pretty  constantly  the  various  exanthemata.  Measles 
and  whooping-cough  are  the  two  diseases  with  which  it  is  most 
commonly  associated. 

In  measles  the  pulmonary  mucous  membrane  is  particularly- 
liable  to  inflammation,  and  sometimes  it  is  seriously  afiected, 
producing  capillary  bronchitis,  and  even  bronchopneumonia. 

The  mortality  of  bronchitis  among  young  children  constitutes 
it  one  of  the  most  fatal  of  diseases. 

The  general  symptoms  of  the  acute  form  depend  on  the  extent 
to  which  the  respiratory  tract  is  involved.  If  the  larger  tubes  are 
principally  aflected,  and  the  smaller  bronchi  have  escaped,  the 
constitutional  disturbance  is  moderate,  and  the  child  may  be  up 
and  have  an  appetite  for  food ;  but  if  the  seizure  has  been  sudden 
and  severe,  and  the  smaller  ramifications  of  the  tubes  are  impli- 
cated, there  may  be  considerable  dyspnrea  and  paroxysms  of  cough, 
coated  tongue,  high-colored  urine,  elevation  of  temperature,  head- 
ache, and  thirst.  If  the  child  is  old  enough  to  talk,  and  to  express 
its  feelings  intelligibly,  it  will  complain  of  soreness  and  even  pain 
over  the  sternum,  au  irritation  in  the  trachea,  and  a  sense  of  con- 
striction at  or  about  the  epigastrium  corresponding  to  the  insertion 
of  the  diaphragm.  The  cough  is  frequent,  hoarse,  and  tearing, 
and  it  persists  whether  the  child  is  awake  or  asleep,  while  it  will 


BEONCHITIS.  415 

often  raise  itself  np  in  bed  unconsciously,  from  the  severity  of  the 
paroxysms,  as  if  frightened,  and  look  about  it  in  amazement.  The 
face  is  generally  flushed  and  heated  in  strong  children,  and  there 
is  headache  and  restlessness,  the  pulse  is  full  and  frequent,  the 
temperature  is  elevated  from  99°  to  102°  or  103°  ;  frequently  it  is 
not  above  100°,  and  in  many  severe  cases  when  the  pulmonary 
condition  denotes  considerable  danger,  it  is  scarcely  raised  above 
the  normal  standard,  though*  the  pulse  may  reach  liO,  and  the 
respirations  be  50  or  60  per  minute,  with  noisy  breathing  and 
prolonged  expiration.  In  these  cases  the  nervons  excitement  is 
great,  and  exhaustion  is  evident,  and  there  is  often  a  good  deal  of 
mucus  in  the  tubes,  indicated  by  catarrhal  sounds  and  loose 
cough;  When  the  temperature  remains  low  or  falls,  and  the 
pulse  and  respirations  are  quick,  debility  is  the  chief  element  to 
contend  with,  unless  there  is  enough  mischief  in  the  lung  to 
account  for  the  constitutional  condition.  If  the  pulse  is  quick, 
the  respiration  is  usually  quick  also,  and  as  the  one  falls  so  does 
the  other ;  but  it  will  often  be  observed,  when  there  is  nothing  in 
the  lung  to  account  for  it,  that  the  pulse  drops  in  frequency  and 
improves  in  quality,  whilst  the  respiration  remains  quick  for  a 
considerable  time,  and  only  falls  to  the  normal  standard  as  the 
strength  is  re-established.  In  very  young  children  of  a  few 
months  old,  who  have  never  been  strong  from  birth,  there  may  be 
loud  mucous  rattling  over  the  back  of  the  chest,  and  wheezing  at 
each  inspiration  ;  they  may  vomit  all  the  food  they  take  from 
the  violence  of  the  cough,  so  that  it  becomes  important  to  seize 
the  opportunity  of  giving  nourishment  immediately  afterwards ; 
and  if  this  plan  is  carried  out,  many  cases  that  appear  hopeless 
may  be  saved.  These  symptoms,  which  increase  in  severity  at 
night,  and  may  be  followed  by  convulsions,  are  not  uncommon  in 
cases  of  bronchitis  complicated  with  whooping-cough. 

The  cough  of  children,  as  of  adults,  is  much  influenced  by  the 
position  they  assume  in  bed.  When  they  sink  low  down  with 
the  head  bent  forward  on  the  thorax,  the  cough  is  distressing,  and 
though  worn  out  and  weary,  they  are  prevented  from  sleep  by 
the  constant  and  harassing  irritation ;  it  is  almost  useless  to 
rectifj^  their  position  and  to  raise  them  up  in  bed,  for  they  quickly 
sink  down  again  with  the  head  buried  in  the  clothes. 

The  character  of  the  cough  is  not  much  guide  as  to  the  nature 
of  the  bronchitis  in  an  early  stage,  though  some  writers  have 


416  DISEASES    OF    CHILDEEN. 

attacTied.  great  importance  to  it.  "  A  bad  sign,  furtlierraore,  is 
when  the  children  cough  more  when  laid  on  one  or  the  other  side 
than  on  the  back,  for  this  cough  in  most  cases  is  due  to  great 
material  alterations  in  the  pulmonary  structure.  Children  with 
simple  bronchitis  cough  less  in  the  dorsal  decubitus  than  in  the 
upright  posture ;  no  difference  can  be  noted  in  them  between  the 
lateral  and  the  dorsal  decubitus."*  Still  it  must  be  admitted 
that  they  often  get  much  ease  when  taken  out  of  bed  and  nursed 
in  the  lap.  ' 

On  a  physical  examination  of  the  thorax,  the  chest  is  found  to 
be  resonant  throughout,  and  loud  rhonchi  of  a  sonorous  character 
are  heard  over  the  upper  lobes  of  the  lungs  posteriorly,  especially 
between  the  scapulae ;  whilst  the  respiration  may  be  clear  in  the 
lower  lobes.  In  children  of  good  constitution  the  disease,  even 
when  very  acute,  does  not  invariably  extend  beyond  the  larger 
bronchi.  If  the  symptoms  increase,  sibilant  rhonchi  (sounds  less 
hoarse  and  large,  but  more  shrill  than  the  former),  denoting  impli- 
cation of  the  smaller  bronchi,  are  heard  in  the  inferior  lobes,  and 
there  is  oppression  and  weight  at  the  epigastrium.  In  a  day  or 
two,  secretion  is  poured  out  from  the  bronchi,  the  cough  becomes 
moister,  and  the  sputa  are  thin  and  frothy.  If  the  cough  is  severe 
there  may  be  streaks  of  blood  in  the  expectoration,  but  it  soon 
changes  its  character,  and  becomes  semi-transparent,  or  of  a  faint 
yellow  color.  Later  on  it  is  of  a  yellowish-green,  and  is  more 
viscid  and  opaque. 

Rhonchus  and  sibilus  may  occur  together  at  the  same  time,  and 
they  generally  do,  but  they  may  be  present  independently  of  each 
other.  The  same  may  be  said  of  the  large  and  small  crepitation, 
the  one  heard  in  the  large  and  the  other  in  the  small  bronchial 
tubes  when  there  is  an  excess  of  fluid  in  them.  Just  as  sibilus  is 
a  more  important  sound  than  rhonchus,  so  is  small  crepitation 
than  large  crepitation,  because  it  denotes  the  implication  of  the 
ramifications  of  the  bronchial  tubes.  I  have  described  the  course 
which  bronchitis  usually  takes,  but  all  cases  do  not  run  into  the 
moist  stage,  or  that  in  which  crepitation  is  produced.  'Now  and 
then  the  disease  stops  short  of  this.  Rhonchi  and  sibili  may  not 
proceed  further,  but  be  succeeded  by  the  normal  respiratory  mur- 
mur, without  any  secretion  being  poured  out.  All  practitioners 
have  seen  cases  where  rhonchus  and  bronchial  breathing  have  been 


*  Vogel  on  Diseases  of  Children,  1874,  p.  284. 


BRONCHITIS.  417 

the  only  physical  signs  heard  in  the  lung.  Ringing  cough,  sore- 
ness of  the  chest,  hurried  respiration,  flushed  face,  and  fever  have 
been  the  leading  symptoms.  Three  or- four  days  later  the  disease 
had  passed  away  without  any  secretion  taking  place.  I  do  not 
think  this  is  frequent ;  one  or  two  attacks  may  end  in  this  way, 
but  subsequent  seizures  are  sure  to  be  followed  by  copious  secretion. 
In  young  children,  if  there  is  loud  rhonchus,  it  is  nearly  always 
succeeded  by  moist  sounds,  and  the  secretion  so  poured  out  often 
causes  dyspnoea  and  death.  In  1869  I  attended  a  boy  ten  years 
of  age,  who  had  been  laid  up  with  cough  and  febrile  symptoms 
for  three  days.  When  I  saw  him  on  the  fourth  day  he  had  be- 
come much  worse,  his  breathing  was  hurried  and  difficult  (40  per 
minute),  nostrils  active,  face  flushed,  pulse  100.  Loud  rhonchus 
and  sibilus  with  shrill  musical  sounds  were  heard  throughout  the 
lungs,  but  percussion  was  clear  both  in  front  and  back  of  the  chest, 
and  the  heart's  sounds  were  normal.  There  was  no  history  of 
asthma,  but  I  suspected  a  certain  amount  of  spasm  in  the  case.  A 
grain  of  calomel  was  given  on  sugar,  and  a  dose  of  a  mixture,  con- 
taining a  few  grains  of  nitrate  of  potash  and  a  sixth  part  of  a 
grain  of  tartarated  antimony,  every  four  hours.  A  poultice  was 
applied  to  the  chest.  J^ext  day  he  was  better,  and  three  days 
later  he  was  well,  without  any  secretion  into  the  air-passages  hav- 
ing taken  place.     A  very  similar  case  is  described  by  Dr.  Latham.* 

The  next  change  in  severe  cases  is  the  disappearance  of  all 
glairiness  in  the  sputa,  and  a  purulent  nummular  condition,  which 
denotes  the  decline  of  the  disease.  This  may  happen  in  three  or 
four  days,  or  it  may  be  delayed  for  a  w^eek  or  more ;  and  the  puru- 
lent secretion  which  we  estimate  as  a  most  favorable  sign  may  be 
only  slightly  marked.  Any  return  of  the  glairy  watery  secretion 
denotes  fresh  bronchial  irritation.  Congestion  of  the  mucous 
membrane  diminishes,  oppression  is  relieved,  and  loose  bubbling 
crepitation  is  heard  ;  but  if  the  disease  extends  into  the  vesicular 
sti'octure  of  the  lungs,  the  face  becomes  dusky  and  anxious,  and 
the  breathing  is  embarrassed.  In  some  cases  the  secretion  is  more 
organized,  and  takes  on  the  form  of  croupal  exudation,  being 
moulded  to  the  shape  of  a  bronchial  tube. 

When  the  inflammation  is  severe,  the  elasticity  of  the  lungs  is 
greatly  impaired,  and  the  lobules  becoming  distended  and  weak- 

*  Clin.  Med.,  vol.  ii,  New  Syd.  Soc,  1879,  p.  118. 
27 


418  DISEASES   OF   CHILDREN. 

eued,  the  air  is  imprisoned  and  cannot  escape.  "When  this  takes 
place  the  vesicular  murmur  is  abolished,  and  there  is  urgent  dysp- 
noea, and  wheezing  sounds  are  heard  throughout  the  chest.  The 
character  of  the  crepitation  varies  according  to  the  size  of  the  im- 
plicated tubes.  When  secretion  is  fairly  established,  coarse,  loose, 
and  moist  crepitation  are  heard  over  the  larger  tubes,  and  small 
crepitation  over  the  smaller  ones;  and  the  sounds  are  so  varied 
and  peculiar  in  some  cases  as  to  be  whistling  and  musical — analo- 
gous in  certain  instances  to  the  rush  of  air  and  fluid  through  a 
narrow  thin  tube.  In  severe  cases  it  is  extremely  difficult  to 
distinguish  the  line  which  separates  inflammation  of  the  finer 
bronchial  tubes  from  that  of  the  vesicular  structure.  The  real 
distinguishing  mark  is  the  absence  of  dulness  in  the  first  case  and 
its  invariable  presence  in  the  latter.  The  cough  in  pneumonia  is 
much  more  tearing  and  painful,  the  child  seems  to  dread  it,  the 
dyspnoea  is  more  urgent,  and  there  is  a  further  rise  in  temperature. 
In  young  children,  the  secretion  into  the  bronchi  is  sometimes  so 
jjrofuse  as  to  give  rise  to  suftbcative  catarrh  and  convulsive  cough, 
because  the  mucus  is  drawn  back  into  the  smaller  tubes  and  can- 
not escape;  and  when  they  are  so  distended  no  air  can  be  heard 
to  enter  the  chest.  In  these  cases  there  is  often  a  good  deal  of 
oppression,  tightness,  and  pain  at  the  chest,  dyspnoea,  and  restless- 
ness. The  child  is  flushed  in  the  face;  the  skin  is  hot  or  perspir- 
ins:,  and  the  veins  about  the  neck  distended  from  the  circulation 
being  impeded  through  the  right  heart ;  the  tips  of  the  fingers  are 
livid,  and  the  countenance  is  dusky.  In  severe  cases,  clots  form 
in  the  heart  or  pulmonary  artery,  the  pulse  increases  in  frequencj^ 
or  is  intermittent  and  feeble,  whilst  the  temperature  falls,  and  the 
Bkin  is  bedewed  Avith  a  clammy  sweat.  There  is  great  danger  in 
this  condition,  and  in  many  cases  the  next  alarming  stage  is 
reached.  The  child  becomes  more  drowsy  and  unconscious,  and 
there  is  difficulty  in  rousing  it  to  take  nourishment.  It  probablj'- 
couccbs  less,  thoucrh  the  air-tubes  are  more  loaded,  because  there 
is  no  strength  to  expectorate;  the  pulse  befcomes  more  rapid  and 
feeble,  and  the  respiration  is  quick,  short,  and  silent.  In  conse- 
quence of  the  circulation  being  nearly  arrested  in  the  lungs  and 
the  right  cavities  of  the  heart,  the  child  may  die  at  any  moment 
from  suflbcation,  with  convulsions,  or  coma. 

We  sometimes  meet  with  acute  bronchitis  in  children  of  a  few 
months  old,  who  cough  and  breathe  badly  for  weeks  before  the 


BRONCHITIS.  41 9 

affection  is  fully  developed.  The  children  have  perhaps  been 
brought  up  by  hand,  and  are  feeble  and  flabby  ;  they  breathe  badly 
at  night  from  an  accumulation  of  phlegm  ;  the  bowels  are  relaxed, 
and  the  motions  greenish  or  white ;  the  respirations  are  40  per 
minute,  and  the  expiration  is  noisy  and  wheezing ;  the  pulse  is 
quick,  but  the  temperature  not  much  elevated.  The  cough  may 
be  so  great  that  the  food  is  vomited,  and  the  children  v\'aste  in 
consequence.  Bronchitis  is  sometimes  complicated  with  laryn- 
gismus. 

The  indications  of  danger  are  urgent  dj'spnoea,  livid  or  dusky 
features,  quick  pulse,  sweating  skin,  and  failure  of  strength.  In 
capillary  bronchitis  the  danger  to  life  is  greater,  because  the 
swelling  of  the  tubes  interferes  with  the  aeration  of  the  blood  ; 
and  also  because  there  is  a  great  tendency  to  collapse  of  the  lung. 

In  some  children  who  have  suffered  from  bronchitis  for  only 
three  or  four  days,  the  skin  breaks  out  somewhat  suddenly  in  a 
clammy  sweat ;  the  eyes  are  dim  and  the  lids  half  closed,  whilst 
the  face  is  pallid  and  the  lips  blue.  The  child  is  perpetually  rest- 
less, drawing  up  its  legs,  throwing  its  arms  wildly  about,  and 
attempting  to  turn  from  side  to  side.  The  pulse  is  rapid  and 
small ;  the  respirations  60  or  70  per  minute,  short,  shallow,  and 
entirely  diaphragmatic.  The  upper  lobes  of  the  lungs  are  fairly 
resonant  on  percussion,  and  the  respiration  is  accompanied  with 
loud  rhonchus  in  this  situation.  Whistlins:  tubular  breathins: 
is  also  heard  in  the  centre  and  lower  lobes,  and  some  parts  of  the 
chest-wall  are  more  resonant  than  others.  The  child,  even  if  sup- 
ported by  food  and  stimulants,  too  frequently  relapses  into  drowsi- 
ness and  coma,  or  dies  in  a  fit  of  convulsions.  In  these  cases  some 
degree  of  catarrhal  pneumonia  or  collapse  of  the  lung  may  be 
found  after  death. 

Chronic  bronchitis  is  a  sequel  to  the  acute  form,  or  it  may  result 
from  neglected  colds  and  a  low  form  of  inflammation.  If  the 
general  health  has  been  reduced,  or  the  child  is  delicate,  it  is  a 
very  obstinate  complaint.  JSTot  uncommonly  it  will  be  found 
associated  with  renal  disease.  A  case  of  this  kind  was  under 
my  care  in  1876,  where  the  bronchial  excitement  followed  des- 
quamative nephritis;  then,  too,  it  is  often  kept  up  by  tubercular 
disease  of  the  lung  and  dilatation  or  valvular  disease  of  the  heart, 
which  interfere  with  the  pulmonary  circulation,  and  induce  con- 
gestion of  the  bronchial  ramifications.  Strumous  and  rickety 
children  are  also  liable  to  this  complaint.     When  it  persists  in 


420  DISEASES   OF   CHILDREN. 

mild  weather,  and  in  spite  of  careful  management,  it  should  put 
us  on  the  lookout  for  tubercle;  dift'used  bronchial  sounds  through 
the  chest  of  any  continuance,  particularly  if  the  temperature  rises 
persistently  in  the  evening,  or  is  fluctuating,  are  very  suggestive  of 
organic  mischief  in  young  subjects.  In  the  cold  weather  of  spring 
and  winter,  young  children  are  liable  to  subacute  attacks  of 
bronchitis,  with  feverishness,  wheezing,  and  troublesome  cough. 
Ehonchi  and  loose  mucous  rales  maj^  be  heard  over  the  front  and 
back  of  the  chest,  and  the  pulse  and  breathing  are  both  quick- 
ened. If  dentition  is  going  on,  the  appearance  of  every  new  tooth 
is  a  signal  for  fresh  pulmonary  irritation,  because  tlie  general 
health  is  lowered  and  the  child  is  too  weak  to  resist  the  changes 
of  weather.  When,  on  the  other  hand,  there  is  free  secretion 
from  the  bronchial  tubes,  with  habitual  cough  and  shortness  of 
breath,  the  pulmonary  tissue  becomes  impaired  and  emphysema 
results.  This  is  more  common  in  adults.  The  tubes  become  di- 
lated, and  the  pulmonary  tissue  shrinks  and  wastes. 

Collapse  of  the  lung  is  one  of  the  consequences  of  bronchitis,  and 
it  has  been  asserted  by  some  that  it  may  either  lead  to  pneumonia, 
or  to  a  more  serious  condition.  The  collapsed  portions  of  the  lung 
require  to  be  distinguished  from  pneumonic  consolidation  ;  they 
are  not  really  pneumonic,  for  although  of  a  venous  red  or  plum 
color,  and  not  crepitating  under  the  finger,  they  are  wanting  in 
firmness.  They  bear  no  traces  of  inflammatory  exudation  and 
sink  when  placed  in  water.  Moreover,  they  can  be  inflated.  When 
the  secretion  from  the  bronchial  tubes  becomes  copious  and  or- 
ganized, a  plug  of  mucus  is  apt  to  be  carried  along  one  of  their 
ramifications  till  it  is  arrested,  so  that  it  cannot  pass  in  any  direc- 
tion. In  expiration,  the  air  behind  the  obstruction  dislodges  it  to 
some  extent  and  passes  outwards,  but  the  act  of  inspiration  draws 
it  back  again  into  the  tube,  where  it  becomes  wedged,  and  does 
not  permit  any  air  to  enter  the  collapsed  lung.  "Its  mechanism 
is  very  simple,  and  is  admirably  illustrated  by  an  experiment  of 
Mendelsohn  and  Traube.  They  introduced  a  shot  into  the  bron- 
chus of  a  living  dog,  and  the  lung  beyond  the  shot  became  col- 
lapsed and  thoroughly  emptied  of  air.  A  solution  of  gum  injected 
into  the  bronchi  produced  the  same  result.  The  air  gradually 
found  its  way  out  past  the  obstruction,  and  was  expelled  during 
expiration,  but  was  prevented  entering  again  during  inspira- 
tion.     So  it  is  with  a  plug  of   tenacious  mucus    at  the  bifur- 


BRONCHITIS.  421 

cation  of  a  bronclius.  It  acts  the  part  of  a  ball-valve  in  a  syringe  ; 
each  expiratory  blast  may  dislodge  it  so  far  as  to  admit  of  the  escape 
of  air  around  it,  but  not  so  far  as  to  prevent  its  falling  back  into 
its  old  position,  and  thus  closing  the  passage  against  the  ingress 
of  air  during  inspiration.  This  condition  of  things  leads  to  the 
emptying  and  consequent  collapse  of  the  air-vesicles  beyond  the 
seat  of  obstruction,  with  attacks  of  dyspnoea,  more  or  less  severe 
according  to  the  size  of  the  portion  of  lung  aftected,  and  more  or 
less  enduring  according  to  the  period  which  elapses  before  the  ob- 
struction is  removed."* 

Pathology  of  Acute  and  Chronic  Bronchitis. — In  health  the  mucous 
membrane  of  the  bronchi  and  their  smaller  ramifications  is  smooth 
and  uniform,  and  pours  out  just  enough  mucus  to  keep  them  moist 
and  lubricated,  and  to  prevent  dryness.  When  from  congestion 
and  hyperfemia  of  the  membrane,  an  abnormal  quantity  of  mucus 
is  secreted,  it  accumulates  in  the  bronchi  and  dyspnoea  is  the 
result.  The  larger  bronchi  maybe  alone  affected,  and  the  smaller 
escape,  or  both  may  be  involved  when  the  disease  is  much  more 
serious  ;  but  it  is  seldom  that  all  are  alike  affected,  and  one  lung 
may  be  much  more  involved  than  the  other.  The  inflamed 
mucous  membrane  is  of  a  pinkish  hue,  the  vessels  are  injected  and 
arborescent,  and  if  the  attack  goes  on,  the  mucous  membrane  be- 
comes darker,  of  a  dusky  scarlet  tint,  thickened,  and  of  a  soft  vel- 
vety appearance,  being  covered  with  mucus.f  In  the  bronchitis 
of  measles,  the  mucous  membrane  is  covered  with  spots  similar 
to  those  on  the  skin,  and  in  small-pox  pustules  have  been  met  with 
in  the  trachea  and  larger  tubes.  The  bloodvessels  are  overloaded, 
and  with  increased  exudation  from  the  serum  of  the  blood  there 
is  an  oedematous  state  of  the  tissues,  and  the  mucus  presents  an 
increased  number  of  cells.  The  secretion  is  at  lirst  thin  and  frothy, 
with  a  good  deal  of  air  ;  then  it  becomes  tenacious  and  glairj^, 
and  mixed  with  purlulent  secretion.     "  When  pus-cells  present 

*  Fuller  on  Diseases  of  the  Lungs,  1867,  p.  325. 

f  "  Ulceration  of  the  mucous  rnembrane  of  the  trachea  and  larger  bronchi,  which  is 
occasionally  met  with  in  the  bronchitis  of  adults,  I  have  never  observed  but  once.  In  ^ 
that  case,  a  little  boy,  twenty  months  old,  who  had  suffered  from  a  not  very  severe 
attack  of  bronchitis,  in  the  course  of  which,  however,  he  had  had  occasional  diffi- 
culty in  deglutition,  with  return  of  fluids  by  the  nose,  died  rather  suddenly.  The 
only  remarkable  appearance  besides  a  general  redness  of  the  bronchial  tubes,  consisted 
in  the  presence  of  several  small  excavated  ulcerations  or  erosions  in  the  upper  part  of 
the  larynx,  just  above  the  chordje  vocales." — West,  On  the  Diseases  of  Infancy  and  Child- 
hood, 1859,  2d  edition,  p.  295. 


422  DISEASES    OF    CHILDREN. 

themselves  in  large  numbers,  they  are  probably  also  to  some  extent 
produced  by  the  proliferation  of  the  subepithelial  cells  of  the  con- 
nective tissue."* 

Treatment. — In  the  acute  variety  the  first  step  to  insist  upon  is 
to  put  the  child  to  bed,  and  then  to  direct  our  treatment  accord- 
ing to  the  age  and  severity  of  the  attack.  If  the  larger  tubes  of 
the  lungs  are  implicated,  and  there  is  heat  of  skin  and  febrile  dis- 
turbance, a  warm  bath  and  a  saline  diaphoretic  mixture  will  be 
advisable,  and  this,  by  inducing  a  free  action  of  the  skin  and  kid- 
neys, may  cut  short  the  attack.  A¥hen  the  symptoms  are  of  a 
more  serious  character,  more  active  treatment  will  be  required. 
Venesection  or  leeching  is  rarely  required.  I  have  never  found  it 
necessary  to  employ  either  in  the  case  of  a  child,  but  I  can  under- 
stand that  when  the  respiration  is  greatly  accelerated,  and  there 
is  so  much  rhonchus  as  to  indicate  great  congestion  of  the  vessels, 
it  might  prove  serviceable.  In  children  the  consitution  is  usually 
not  robust  enoug-h  to  stand  it,  and  it  must  not  be  reckoned  amonsj 
the  appropriate  remedies.  "•  In  children  I  believe  it  is  never  neces- 
sary to  open  a  vein,  for  leeches  on  the  chest  form  a  convenient  and 
etiective  substitute  for  phlebotomy. "f  Small  doses  of  tartar  emetic, 
with  the  liquor  amm.  acet.  (Form.  7),  will  generally  suffice,  and  if 
they  should  excite  vomiting  at  first  it  will  be  no  drawback.  The 
one-sixth  or  one-eighth  of  a  grain  in  solution  with  the  liq.  amm. 
acet.  every  three  or  four  hours  favors  secretion,  and  lessens  the 
severity  of  the  symptoms.  It  is  important  to  change  the  hot  dry 
skin  into  a  moist  and  relaxed  one,  and  the  same  applies  to  the 
congested  mucous  membrane  of  the  bronchi.  Even  in  these  cases 
it  is  necessary  to  be  watchful  and  cautious,  as  depression  and  ex- 
haustion may  quickly  ensue.  When  antimony  is  employed,  strong 
children  only  should  be  selected,  for  a  few  doses  will  generally 
produce  a  rapid  and  lowering  eflect,  and  they  cannot  be  too  care- 
fully watched.  Pallor  of  the  face,  duskiness  of  lips,  sweating  skin, 
and  increased  bronchial  rales  are  to  be  looked  for,  and  the  local 
as  well  as  the  constitutional  condition  will  grow  worse  instead  of 
improving  in  young  subjects  unless  they  are  vigorous.  The  vinum 
antimoniale  is  generally  sufficient  to  control  ordinary  cases.  In 
infants  and  very  young  children  ipecacuanha  is  preferable,  and 
even  this  milder  remedy  should  be  watched,  and  combined  with 

*  Fenwick,  Medical  Diagnosis,  p.  45. 
f  Fuller,  o\).  cit.,  p.  316. 


BRONCHITIS.  423 

the  spt.  ffither.  nitr.  or  the  liq.  amm.  acet.  I  have  sometimes  given 
hydrocyanic  acid  in  addition  to  arrest  vomiting.*  If  the  child 
becomes  pale  after  a  few  doses,  and  the  skin  is  moist  and  the  pulse 
weak,  or  if  the  temperature  is  falling,  it  should  be  discontinued, 
and  ammonia,  nourishment,  and  even  wine  or  brandy  employed. 
In  very  young  children,  when  the  face  is  dusky,  and  there  is 
drowsiness,  with  loose  coarse  rales  over  the  chest,  there  is  no  better 
combination  than  the  carbonate  of  ammonia  and  spirit  of  chloro- 
form.f  Even  in  these  cases  I  have  sometimes  known  an  emetic 
of  ipecacuanha  and  sulphate  of  zinc  have  a  remarkable  rallying 
effect  by  dislodging  a  large  quantity  of  bronchial  mucus.:}:  A  few 
drops  of  brandy  should  be  given  in  milk  frequently,  or  a  small 
quantity  of  champagne  in  soda-water;  water  arrowroot,  to  which 
brandy  is  also  added,  and  beef  tea,  veal,  or  chicken  broth,  will  be 
demanded.  Under  this  treatment  the  temperature  may  fall  from 
102.4°  to  100°,  and  the  pulse  from  164  to  140  in  the  course  of  a 
few  hours.  In  the  case  of  strong  children,  with  much  febrile  ex- 
citement and  sthenic  action,  it  may  be  well  to  give  a  powder  of 
calomel,  James's  powder,  and  nitrate  of  potash§  (Form.  62).  I 
find  this  an  excellent  combination  to  act  on  the  skin  and  bowels, 
exciting  free  action  in  these  organs,  and  so  reducing  the  fever  and 
controlling  the  constitutional  disturbance.  Four  of  these  powders 
are  invariably  enough  in  my  experience  to  bring  about  the  desired 


*  Formula  60: 

B.  Liquor,  amm.  acet., §j 

Acid,  hydrocy.  dil., 


Vin.  antimonialis, 
Syr.  scillfe, 
Aquam  ad. 


ti^viij 

gss. 
giv.— M. 


A  dessertspoonful  every  four  hours.     For  a  child  five  or  six  years  old. 
t  Formula  61  : 

K.  Amm.  carb.,       .        .         . gr.  ,iv 

Spt.  chloroform., ttjJxx 

Syr.  tolut., ^ss. 

Aquam  ad ^ij. — M.     r 

A  teaspoonful  every  four  hours.     For  a  child  a  year  old. 
J  See  the  action  of  emetics  in  the  treatment  of  bronchopneumonia,  Chap.  XXXVI, 
and  in  Chap.  II. 
§  Formula  62 : 

B.  Hydr.  chlorid., gr.  ij 

Pulv.  antimonialis, gr.  viij 

Potass,  nitrat., 

Sacchari,  aa gr.  xij. — M. 

Et  divide  in  pulveres  iv.     One  every  four  or  six  hours.     For  a  child  five  years  old. 


42  i  DISEASES   OF   CHILDREX. 

result,  and  it  must  be  nuderstood  that  the  administration  of  a 
remedy  like  calomel  is  only  called  for  under  the  conditions  above 
enumerated.  When  the  disease  is  limited  to  the  laro;er  bronchi, 
and  there  is  great  hj-persemia  of  the  vessels,  it  has  an  extraordi- 
nary effect  upon  the  capillary  circulation.  Whilst  it  encourages 
secretion,  it  subdues  the  tendenc}"  to  inflammatory  action,  and  the 
plastic  eff"usion  which  frequentlj^  follows  it.  When  the  cough  is 
very  troublesome,  mixture  of  syrup  of  squill  and  syrup  of  tolu  will 
be  useful,*  and  if  the  bowels  are  sluggish,  syrup  of  senna  may  be 
added. t  In  some  mild  cases  the  citrate  or  bicarbonate  of  potash, 
with  ipecacuanha,  will  be  found  a  suitable  remedy  if  the  tongue 
be  coated  and  an  alkali  is  indicated. +  If  the  bowels  are  sluggish, 
a  simple  soap-and-water  enema,  or  a  drachm  of  the  syi'up  of  senna 
or  rhubarb,  will  be  suiHcient  to  excite  peristaltic  action.  The 
temperature  of  the  room  should  be  65°  to  70°,  and  in  cold  weather 
a  bronchitis  kettle,  or  the  steam  of  boiling  water,  to  moisten  the 
atmosphere  of  the  apartment,  will  be  useful.  When  there  is  much 
restlessness  henbane  will  be  required,  or  even  h^'drate  of  chloral  if 
there  is  vascular  excitement ;  but  this  last-named  fashionable  drug, 
like  opium,  should  be  used  with  caution  lest  it  check  the  secretion. § 
Chloral,  too,  requires  great  care  in  its  employment,  as  it  may  de- 
press the  respiratory  centres  and  the  nervous  ganglia  of  the  heart. 

*  Formula  63 : 
R.  Syr.  tolut., 
Syr.  scillae, 

Aquam,  aa gss. — M. 

A  teaspoonful  when  the  cough  is  troublesome, 
f  Formula  64 : 

R.  Syr.  tolut., 
Syr.  scillae, 
Syr.  sennte,   sa  .         .         .         .         .         .         .         .         .     ^ss. — M. 

A  teaspoonful  twice  or  three  times  a  day,  or  when  the  cough  is  troublesome. 
X  Formula  65 : 

R.  Potass,  citrat.,  vel 

Potass,  bicarb.,  .........     ^ss. 

T.  camph.  comp,, 

Yin.  ipecac,  aa ^j 

Syr.  scillae,  .........     ^ss. 

Aquam  ad ^ij. — M. 

A  teaspoonful  every  three  liours.     For  children  from  one  to  two  years  of  age. 
^  The  physiological  and  tlierapeutical  action  of  hydrate  of  chloral  are  considered 
in  Chap.  XXXVIII,  On  Pneumonia. 


BRONCHITIS.  .  425 

When  the  nervous  element  prevails,  as  it  does  in  some  children,  a 
sedative  is  useful  to  procure  rest  and  sleep,  and  for  this  end  a  few 
grains  of  the  bromide  of  potassium,  v^'ith  or  without  the  chloral, 
or  even  Dover's  powder  alone,  will  be  serviceable.  When  the  secre- 
tion is  freel}^  established,  such  expectorants  as  ipecacuanha,  squill, 
and  senega  will  be  necessary.*  As  regards  local  applications,  a 
turpentine  stupe  or  a  warm  poultice,  made  with  equal  parts  of 
linseed  meal  and  bread,  should  be  applied  to  the  chest  or  back. 
In  very  young  children  it  is  an  excellent  plan  to  envelop  the  chest 
(front  and  back)  in  cotton-wool,  and  to  cover  this  with  oil  silk. 
This  acts  like  a  poultice,  and  is  far  better  than  the  application  of 
stupes  and  poultices,  while  the  child  is  not  distressed  by  frequent 
chano;e  of  clothing. 

I  have  observed  immense  relief  in  many  cases  from  placing 
young  children  as  much  as  possible  on  the  face  in  bronchitis ;  but 
this  can  onlj^  be  done  with  infants  satisfactorily.  It  relieves  the 
cough  and  respiration,  and  the  tendency  of  the  secretion  to  gravi- 
tate to  the  lower  and  posterior  surface  of  the  lungs  is  lessened. 
The  child  should  be  held  across  the  arm  of  the  nurse,  with  its  face 
downwards,  and  kept  for  hours  together  in  this  position.  In  the 
winter  of  1876,  I  attended  a  child  seven  months  old,  with  acute 
bronchitis,  and  I  am  satisfied  that  recovery  was  in  a  great  measure 
due  to  the  position  the  child  was  kept  in  during  the  catarrhal 
stage,  when  the  secretion  was  copious  and  the  cough  exhausting. 
The  child  was  weak,  and  at  one  time  unable  to  cough  from  the 
loaded  state  of  the  tubes,  and  the  weakness  of  the  respiratory  act. 
There  was  danger  of  the  elasticity  of  the  lung  being  destroyed  by 
the  accumulation  of  phlegm  in  the  dependent  parts  of  the  chest. 
I  therefore  had  the  child  turned  on  its  face,  and  laid  across  the 
nurse's  lap  in  a  semi-erect  posture.  It  soon  began  to  improve, 
coughing  up  phlegm  easil}^  and  sleeping  soundly  at  intervals.  An 
emetic  of  ipecacuanha  in  these  cases  at  bedtime  is  sometimes  ad- 

*  Formula  66 : 

R.  Vin.  ipecac, 

Tinct.  scillfe,  aa 'njjxl 

Tinct.  conii, 3j 

Spt.  setlier.  nit., 3J 

Syr.  tolut., .^ss. 

Decoct,  senegse  ad      .......         .     5! v. — M. 

A  dessertspoonful  every  four  hours. 


426  DISEASES    OF   CHILDREN. 

visable,  and  even  at  an  early  stage  it  may  subdue  the  hypersemia 
of  the  tubes,  and  shorten  the  severity  of  the  acute  stao-e.* 

The  duration  of  the  disease  is  uncertain.  It  may  destroy  the 
life  of  an  infant  or  young  child  in  forty-eight  hours,  but  the  ordi- 
nary period  is  from  seven  to  ten  days. 

Treatment  of  Chronic  Bronchitis. — From  the  onset  of  the  attack 
it  is  most  important  to  support  the  patient's  strength.  It  is  never 
necessary  to  abstract  blood,  or  even  to  employ  antimony,  though 
there  may  be  fine  bubbling  rales,  and  other  signs  of  bronchial  in- 
flammation. To  meet  this  condition  Ave  must  Ye\j  on  the  admin- 
istration of  ipecacuanha,  squills,  senega,  and  nitrous  ether.  A 
warm  poultice  to  the  chest,  or  a  turpentine  fomentation  is  best 
and  safest,  with  such  stimulants  as  support  the  circulation  and 
avert  the  tendency  to  sinking  and  fatal  prostration.  When  the 
pulmonary  irritation  is  less  active,  the  .carbonate  of  ammonia  and 
tincture  of  bark  will  be  found  useful. f  An  occasional  emetic  to 
empty  the  bronchial  tubes  at  bedtime  will  promote  sleep  and  insure 
rest.  Alarm  may  sometimes  be  caused  by  children  appearing  as 
if  they  would  choke  in  the  act  of  vomiting,  but  this  never  actu- 
ally happens,  and  no  fear  need  be  apprehended  on  this  ground.  I 
have  seen  great  benefit  follow  the  administration  of  the  syrup  of 
the  iodide  of  iron,  with  a  few  drops  of  ipecacuanha:}:  when  there 
is  cough,  debility,  and  free  secretion  in  the  lungs.  Expectorants 
alone  have  an  injurious  effect,  and  sedatives  are  equally  bad.  The 
necessity  of  using  opium  with  the  utmost  caution  in  young  and 
feeble  children,  for  fear  of  checking  expectoration,  cannot  be  too 
strongly  insisted  on.  The  incessant  cough  depends  on  phlegm 
which  has  accumulated  in  the  air-passages.  Opium  renders  the 
mucous  membrane  insensitive,  consequently  cough  is  no  longer  ex- 

*  See  also  the  action  of  emetics  in  Chap.  II. 
f  Formula  67 : 

li.  Amm.  carb., gr.  viij 

Tinct.  cinch.  CO.,      ........     .^ij 

Syr.  tolut.,       .         .         .         .  ■       .         .         .         .         .     5SS. 

Aquani  ad       ........         .     5iv. — M. 

A  dessertspoonful  three  or  four  times  a  day. 
X  Formula  08: 

li.  Syr.  ferri  iod., ^ss. 

Vin.  ipecac, 3J 

Aquam  ad ,^iij. — M. 

Two  teaspoonfuls  three  times  a  day.  These  prescriptions  are  suitable  for  children  of 
five  or  six  years  old. 


PLEURISY.  427 

cited,  and  the  child  may  die  asphyxiated  from  the  blood  not  being 
sufficiently  decarbonized.  In  older  and  stronger  children  a  seda- 
tive allays  irritation  and  prevents  exhaustion,  if  the  condition  of 
the  mucous  membrane  is  rather  one  of  irritation  and  congestion 
than  of  free  exudation.  When  the  secretion  is  co})ions,  aijd  the 
bronchi  loaded  or  obstructed,  an  emetic  of  ipecacuanha  or  sulphate 
of  zinc  at  night  is  serviceable,  and  when  it  has  acted  well,  a  stimu- 
lating expectorant  and  wine  should  be  employed.  Cod-liver  oil  is 
another  remedy  at  this  stage,  and  is  most  valuable  in  obviating 
the  exhaustion  and  ill-health  which  so  frequently  ensue.  When 
the  secretion  remains  profuse  (bronchorrhcea),  and  the  cough  is 
frequent,  quinine,  the  mineral  acids  (which  are  very  valuable),  iron, 
conium,  and  cod-liver  oil  are  most  to  be  relied  on.  Change  of  air 
to  a  warm  equable  temperature  and  a  generous  diet  will  get  rid 
of  this  condition.  It  is  at  all  times  important  to  attend  to  the 
ventilation  of  the  sleeping  apartments,  w^hich  should  be  dry  and 
airy,  neither  too  cold  nor  too  hot,  but  as  uniform  as  it  is  possible 
to  make  them.  Flannel  should  be  worn  next  the  skin,  and  the 
feet  kept  warm. 


CHAPTER  XXXyil. 

PLEURISY. 

Symptoms:  Of  the  acute  form — General  and  local.  Causes:  Cold  and  exposure — Rheu- 
matic fever  and  the  exanthemata — Tubercle.  Diagnosis:  Generally  easy  of  recogni- 
tion, but  may  be  mistaken  in  some  cases  for  tuberculosis  or  bronchopneumonia — In 
exceptional  cases  for  abdominal  disease  or  encephalitis  when  severe  headache  or  delirium 
is  present — Means  of  distinguishing  the  several  affections.  Prognosis:  Favorable 
when  the  effusion  is  moderate  and  the  disease  is  uncomplicated.  Mokbid  Anatomy  : 
Dryness  of  pleurce — Effusion  of  coagulable  lymph  and  pus — Adhesions — Extreme  effu- 
sion. Treatment  :  Leeches —  Warm  poidtices  to  the  affected  side  —  Calomel  and 
opium — Sudorifics — Free  purgation.  Chronic  Pleurisy:  Causes — Symptoms — Ter- 
minations— Treatment.  Empyema:  Causes — Symptoms — Diagnosis  and  treatment — 
Paracentesis  thoracis — Method  of  operation — Risks  attending  it — Simple  tapping — 
Aspiration — Use  of  the  drainage-tube — Indications  for  the  employment  of  tapping — In- 
jections into  the  pleural  cavity — The  coexistence  of  empyema  vjith  pneumothorax. 

Acute  pleurisy,  or  inflammation  of  the  membrane  which  invests 
the  lung  and  thoracic  walls,  is  a  most  painful  aftection,  since  the 
inflamed  visceral  and  parietal  layers  of  the  pleura  must  necessarily 
rub  against  each  other  during  inspiration  and  expiration,  so  that 
rest  cannot  be  aflforded  them. 


428  DISEASES    OF    CHILDREN. 

Pleurisj'  when  uncomplicated  with  pneumonia  is  held  to  he  rare 
under  five  years  of  age.  Still  it  must  be  admitted  that  the  disease 
is  more  frequent  in  early  life  than  is  generallj^  supposed  ;  for  in  the 
absence  of  d^'spnoea  the  chest  constantly  escapes  examination,  and 
even  if  it  does  not,  a  hmited  degree  of  inflammation  of  the  pleura 
is  not  easy  to  diagnose  during  life. 

The  disease  generally  begins  with  a  rise  of  temperature  and 
rigors,  soon  followed  by  catching  pain  in  one  side  of  the  chest, 
limited  to  one  or  two  intercostal  spaces.  If  pressure  be  made  over 
them  the  patient  winces  and  cries  out.  The  pain  commences  above 
and  to  the  left  or  right  of  one  nipple,  as  the  case  may  be,  and  ex- 
tends through  the  sternum  or  up  to  the  axilla.  The  pain  at  each 
inspiration  resembles  that  caused  by  a  sharp  instrument  penetrat- 
ing the  side.  In  some  cases  nearly  the  whole  side  is  aftected.  If 
the  disease  be  complicated  with  bronchitis  or  pneumonia,  the 
physical  signs  of  these  diseases  are  present.  There  is  dyspnoea 
and  a  short  dry  cough,  and  the  pain  is  aggravated  by  each  inspi- 
ratory effort,  which  is  hurried  and  interrupted.  The  pulse  is 
frequent,  hard,  and  small,  and  it  may  be  tense  ;  the  countenance 
is  distressed  and  anxious,  and  the  face  sometimes  flushed ;  there  is 
high  fever  in  some  cases,  but  it  is  not  so  high  as  in  pneumonia, 
and  it  is  more  subject  to  fluctuation  ;  the  skin  is  hot,  but  moist, 
and  the  tongue  coated;  the  urine  is  scanty  and  high-colored,  its 
specific  gravity  is  also  high,  and  as  in  many  other  acute  inflam- 
matory disorders  there  may  be  a  trace  of  albumen  from  venous 
congestion. 

There  are  exceptions  to  this  general  condition,  the  pain  being 
much  less  in  some  cases  than  in  others ;  it  may  be  absent,  and  the 
breathing  may  be  unaffected  even  when  the  phj'sical  signs  indi- 
cate considerable  eft'usiou.  Indeed,  very  rapid  eft'asion  of  necessity 
relieves  the  characteristic  pain  by  preventing  friction  between  the 
opposed  surfaces  of  the  pleurae.  In  some  cases  quick  breathing 
and  debilitj^  are  the  only  symptoms  which  accompany  eft'usion. 

Dyspnoea  is  a  symptom  which  is  apt  to  mislead  the  young 
practitioner,  more  importance  being  attached  to  it  than  it  fre- 
quently deserves.  It  is  often  present  at  the  commencement  of 
pleurisy,  when  the  pain  in  the  side  is  acute,  and  before  the  effu- 
sive stage  has  been  reached.  The  child  does  not  inflate  his  lung 
completely  by  a  full  inspiration,  because  the  eftbrt  increases  the 
pain  caused  by  the  movements  of  the  thoracic  parietes,  and  the 


PLEUEISY.  429 

pyrexia  wlncli  is  present  has  the  effect  of  accelerating  the  respira- 
tion. "  This  dyspnoea  at  the  commencement,  then,  is  a  false 
dyspnoea,  and  is  not  due,  like  true  dyspnoea,  to  defective  and 
insufficient  h^ematosis,  but  to  the  pain  which  limits  the  respira- 
tory movements  and  destroys  their  normal  rhythm."*  Hence  it 
is  that,  as  the  effusion  increases,  the  pain  diminishes,  and  the  res- 
piration scarcely  exceeds  the  rate  of  health,  when  the  sound  lung 
comes  into  play  from  apex  to  base,  and  takes  on  additional  work. 

The  position  which  the  patient  assumes  in  bed  is  a  matter  of 
some  interest  and  importance.  According  to  my  experience  the 
decubitus  is  usually  dorsal ;  the  patient  cannot  lie  on  the  affected 
side  owing  to  the  pleural  friction  and  the  pain  which  that  position 
entails ;  on  the  other  hand,  lying  on  the  sound  side  causes  dis- 
comfort, since  then  extra  work  is  imposed  on  the  lung  lying 
uppermost,  which  requires  rest  as  its  pleura  is  inflamed.  Still 
the  child  will  assume  any  position  which  enables  it  to  breathe 
with  the  greatest  facility  and  affords  the  fullest  freedom  to  the 
unaffected  lung. 

The  physical  signs  vary  with  the  stage  which  the  pleurisy  has 
reached,  and  according  to  the  strength  and  constitution  of  the 
patient.  AVhen  the  pleura  is  dry  and  inflamed  at  an  early  period 
of  the  illness,  there  will  be  diminished  mobility  of  the  affected 
side  in  consequence  of  the  pain  experienced  on  inspiration.  The 
respiratory  murmur  is  weak  or  indistinct,  a  rough  or  grating 
friction-sound  is  heard  from  the  opposing  congested  and  dry  sur- 
faces rubbing  against  each  other.  It  is  a  peculiar  jerking  inter- 
rupted sound,  as  if  some  structure  was  suddenly  dislocated  ;  the 
patient's  sensations  give  him  the  same  impression ;  whilst  if  the 
hand  be  laid  over  the  part,  a  sudden  rough  jerk  is  communicated 
to  it  as  though  a  rib  had  slipped  over  an  uneven  surface.  The 
position  where  this  is  usually  detected  is  in  the  infra-axillary 
region.  The  sound  disappears  when  adhesion  takes  place  between 
the  surfaces  in  apposition,  as  I  have  explained  when  speaking  of 
pericarditis.  The  percussion-sound  is  unaltered  on  the  affected 
side,  or  at  the  most  the  resonance  in  uncomplicated  pleurisy  is 
only  slightly  diminished,  and  the  respiration  is  puerile  in  the 
unaffected  lung. 

In  the  next  stage,  or  that  of  effusion,  the  movements  of  the 

*  Dr.  Dienlafoy  on  Dyspnoea  in  Acute  Pleurisy,  Gaz.  Hebdom.,  Sept.,  1878. 
Quoted  from  Med.  Times  and  Gaz.,  Oct.,  1878. 


430  DI5EA.SES   OF   CHILDREN. 

cliest-wall  on  the  affected  side  are  diminished,  varying  of  course 
according  to  the  amount  of  fluid  poured  out.  If  the  effusion  is 
considerable  the  lower  part  of  the  chest-wall  bulges  out,  and  if 
very  large,  there  may  be  a  more  general  enlargement  of  the 
affected  side,  a  wider  separation  of  the  ribs,  and.  obliteration  of 
the  intercostal  spaces.  Vocal  fremitus  is  diminished,  in  small 
effusions,  and  abolished  in  large  ones.  The  heart  (as  well  as  the 
liver  and  spleen)  may  be  displaced  in  extensive  pleuritic  effusions, 
and  seem  to  pulsate  out  of  its  normal  position. 

In  cases  of  extensive  effusion  in  children  whose  chest-walls  are 
thin,  fluctuation  may  be  detected  between  the  ribs,  and  the  sur- 
face is  smooth,  tense,  or  even  oedematous.  If  the  chest  is  ex- 
amined carefully  from  before  and  bebind,  enlargement  may  be 
detected' over  the  inferior  ribs  of  the  affected  side.  This  is  often 
very  apparent  when  the  child  is  sitting  up  in  bed,  and  the  physician 
examines  the  chest  from  behind.  He  is  apt  to  think  that  the  dis- 
eased side  must  invariably  measure  more  than  the  sound  one, 
but  there  may  be  considerable  efthsion  without  any  increase  in  its 
dimensions.  A  large  quantity  of  fluid  may  be  present  in  one 
pleura  without  causing  the  side  to  become  larger.  If  several 
ounces  are  present,  the  measurement  of  the  diseased  side  niay  not 
exceed  the  sound  one  by  more  than  an  inch.  This  is  best  ascer- 
tained by  using  the  cyrtometer.  I  have  had  many  opportunities 
of  observing  this  fact  in  pleuritic  effusion  of  adults,  which  some- 
times results  from  the  pressure  of  ovarian  and  other  abdominal 
tumors  obstructing  the  circulation. 

The  elasticity  or  power  of  expansion  in  the  chest-wall  depends 
upon  its  thickness,  the  age  of  the  patient,  and  the  strength  of  the 
constitution.  Hence  it  is  that  in  children  the  ribs  act  with  greater 
freedom,  and  the  ligaments  and  muscles  easily  stretch  before  any 
force  that  may  be  brought  to  bear  on  them,  such  as  the  pressure 
•    caused  from  within  by  pleuritic  effusions. 

Andral*  speaks  of  great  diiatatif)n  of  the  thorax  by  the  fourth 
or  fifth  day  of  an  acute  attack  ;  and  Dr.  Fuller  also  states  that 
there  may  be  bulging  in  the  lower  part  of  the  chest-wall  before 
the  end  of  the  third  day  of  attack,  and  that  other  cases  are  re- 
corded where  the  chest  is  considerably  enlarged  before  the  end  of 
the  fifth  day.  "  In  my  experience,"  he  says,  "  however,  this  early 
enlargement  has  occurred  only  in  childhood,  when  the  chest-walls 

*  Principles  and  Practice  of  Medicine,  by  Sir  T.  Watson,  Bart.,  1857,  vol.  ii,  p.  116. 


rLEURISY.  431 

are  unusuallj  yielding,  and  in  those  children  only  in  whom  the 
costal  pleura  has  suffered  severely,  and  in  whom  the  intercostal 
muscles  being  paralyzed,  and  the  subserous  structure  softened  and 
infiltrated  with  serum,  the  chest-walls  yield  to  the  outward  pres- 
sure with  unusual  readiness."*  In  short,  enlargement  of  the 
affected  side  of  the  thorax  is  the  rule  in  cases  of  extensive  pleural 
effusion  during  childhood,  but  is,  as  I  have  said  before,  by  no 
means  invariable. 

On  percussion  over  the  seat  of  effusion  the  dulness  is  absolute. 
It  may  be  termed  characteristic  when  the  fluid  beneath  is  con- 
siderable ;  but  in  recent  cases,  when  it  is  moderate  in  quantity  and 
the  lung  has  not  suffered  much  compression,  then  the  note  be- 
comes resonant  if  the  patient  shifts  his  position  and  lies  on  the 
sound  side.  When  he  lies  on  his  back,  the  note  is  resonant  over 
the  front  of  the  chest.  When  he  lies  on  his  face  the  fluid  gravi- 
tates to  the  front,  and  the  note  is  dull  in  this  situation,  though  if 
adhesions  be  present  the  fluid  may  be  prevented  from  shifting. 

The  uppermost  part  of  the  chest  always  elicits  a  hollow  sound 
M'hen  struck,  varying  of  course  with  every  attitude  of  the  patient. 
This  is  a  valuable  diagnostic  sign.  Again  it  may  be  noticed  that 
if  the  upper  portion  of  the  lung  has  escaped  compression  and  the 
effusion  does  not  extend  above  the  nipple-line,  the  percussion-note 
is  so  clear  as  to  be  tympanitic.  Respiration  is  heard  in  the  affected 
lung  down  to  the  eftusion ;  but  in  severe  cases,  when  the  pleural 
cavity  is  nearly  full  of  fluid  and  the  lung  is  much  compressed,  the 
whole  side  is  dull.  The  respiratory  murmur  is  absent,  or  there  is 
bronchial  breathing,  with  bronchophony  along  the  spine.  Of 
course  the  sounds  are  altered  and  modified  according  to  the  extent 
of  effusion.  Above  the  line  of  effusion  the  breathing  is  often  harsh, 
tubular,  or  hollow  ;  vocal  vibration  is  increased,  and  in  the  inter- 
scapular region  the  respiration  may  be  loud  and  blowing,  and  the 
voice  bronchophonic.  The  unaffected  side  of  the  chest  is  hyper- 
resonant,  and  the  breathing  puerile. 

In  ordinary  cases,  after  three  or  four  days,  the  pain  and  fever 
abate  and  convalescence  begins. 

The  disease  may  terminate  in  resolution,  or  in  adhesion  of  the 
two  pleural  surfaces,  or  in  eftusion  and  empyema.  But  if  uncom- 
plicated with  tubercle  or  pericarditis,  pleurisy  is  seldom  fatal. 

The  stage  of  absorption  and  resolution  is  characterized  by  the 

*  Diseases  of  the  Lungs,  1867,  p.  181. 


432  DISEASES    OF   CHILDEEN. 

elasticity  in  the  chest-walls  being  regained,  and  by  a  return  to  the 
normal  size.  The  intercostal  spaces  lose  their  distension,  and  vocal 
vibration  returns.  The  percussion-note  gradually  becomes  clearer 
as  the  effusion  is  absorbed,  and  the  lung  begins  to  recover  from 
compression,  except  where  the  exudation  is  thick  and  plastic,  and 
then  the  dulness  is  permanent.  This  is  particularly  the  case  in  the 
lower  portion  of  the  chest,  in  the  axillary  line.  As  regards  auscul- 
tation, the  respiratory  murmur  slowly  returns,  at  first  weak,  short, 
or  harsh,  but  later  on  full  and  complete,  as  in  normal  respiration. 
During  this  process  of  absorption,  the  rubbing  of  the  pleural  sur- 
faces one  against  the  other,  as  at  the  commencement  of  the  dis- 
ease, sometimes  produces  a  friction-sound,  as  in  pericarditis,  when 
the  effused  fluid  is  taken  up  and  the  heart  comes  in  contact  with 
the  roughened  pericardium. 

Causes. — The  disease  may  follow  cold  and  exposure,  a  case  of 
which  came  under  my  notice  a  few  years  ago  in  a  child  six  years 
of  age.  It  ma}'  occur  in  the  coarse  of  rheumatic  fever.  One  of  the 
worst  cases  I  ever  witnessed  was  in  a  boy  of  twelve  years  of  age, 
who  was  suffering  from  acute  rheumatism  complicated  with  pneu- 
monia of  the  left  lung.  It  may  happen  during  one  of  the  exan- 
themata, particularly  scarlet  fever  or  measles  ;  or  be  excited  by 
pericarditis,  or  tubercular  infiltration  of  the  lung.  It  may  also 
accompany  albuminuria.  Dr.  West  mentions  two  cases  which 
followed  peritonitis. 

Diagnosis  and  Prognosis. — Pleurisy  is  not  generally  difficult  of 
detection.  The  presence  of  fever  along  with  the  acute  and  catch- 
ino-  pain  in  the  side,  aggravated  by  a  full  inspiration,  distinguish 
it  from  pleurodynia,  with  which  it  can  scarcely  be  confounded ; 
and  the  physical  signs  clear  up  its  true  nature.  But  the  difliculty 
arises  later  on  Avhen  effusion  occurs;  and  then  if  the  case  is  com- 
plicated with  bronchial  congestion,  pulmonary  tubercle,  or  broncho- 
pneumonia, we  may  be  doubtful  as  to  the  presence  of  fluid.  These 
diseases,  however,  are  most  frequently  bilateral,  whilst  a  pleuritic 
eftusion  is  rarely  so,  though  serum  or  pus  has  been  present  in  both 
pleural  cavities  at  the  same  time. 

If  the  outset  of  the  disease  is  attended  with  purging,  which  is 
not  infrequent,  and  the  pain  is  referred  to  the  abdomen  and  right 
hypochondrium  instead  of  the  side,  and  if  moreover  there  is  bilious 
vomiting,  our  attention  may  be  diverted  from  the  chest  to  the 
abdomen  ;  but  a  careful  consideration  of  all  the  symptoms  ought  to 


PLEURISY.  433 

prevent  us  from  falling  into  error.  These  symptoms,  with  cougli, 
strong  fever,  and  urgent  dyspnoea,  constitute  "  diaphragmatic 
pleurisy."  Pleurisy  may  extend  to  the  pericardium  and  involve 
this  membrane  in  inflammation.*  Like  pneumonia,  the  disease 
sometimes  commences  with  so  much  headache  and  delirium  that 
it  has  been  mistaken  for  encephalitis.  If  there  is  vomiting 
also,  and  the  cough  and  pain  in  the  side  are  slight,  and  the  respi- 
ratory murmur  is  simply  weak,  and  no  friction-sound  can  be  de- 
tected, we  may  overlook  the  complaint.  Still,  if  we  carefully 
review  the  whole  history  of  the  case,  and  consider  the  way  in 
which  the  disease  has  commenced,  we  can  scarcely  fall  into  error. 
As  in  pneumonia,  pleurisy  sets  in  with  much  more  fever  than  is 
present  in  meningitis,  the  heat  of  the  head  is  not  so  great,  and 
there  is  no  squinting  or  intolerance  of  light.  The  child,  if  old 
enough,  can  answer  questions  intelligibly. 

The  difference  in  dulness  between  pneumonia  and  pleurisy  is 
also  a  great  help  in  diagnosis.  In  the  latter  affection  it  is  first 
detected  in  the  lowest  part  of  the  thoracic  cavity,  and  as  .the  dis- 
ease proceeds  it  is  heard  over  the  whole  chest,  which  is  rare  in 
pneumonia.  "  The  dulness  comes  on  much  more  quickly  in  pleurisy 
than  in  pneumonia.  It  has  been  noticed  within  twelve  hours  from 
the  invasion  of  the  disease. "f  Taking  into  consideration  the  in- 
tense and  absolute  dulness  of  pleurisy,  the  greater  rapidity  with 
which  it  occurs,  and  the  serous  effusion  which  may  displace  the 
heart  and  mediastinum,  we  have  good  grounds  for  framing  a 
diagnosis  between  the  two  affections.  Occasionally,  we  have  also 
another  very  characteristic  sign  of  pleurisy  when  fluid  is  poured 
out  around  the  larger  bronchi,  and  the  lung  is  compressed  by  it. 
The  sound  then  heard  is  a  modification  of  bronchophony,  and  is 
known  as  cegophony.  It  is  like  a  distant  tremulous  voice  when 
the  patient  speaks,  resembling  the  squeak  of  Punch,  or,  as  Laennec 
says,  like  the  "  bleating  of  a  goat." 

When  pleurisy  attacks  a  healthy  constitution,  and  is  of  recent 
date,  the  prognosis  is  favorable  ;  but  if  complicated  with  pulmo- 
nary phthisis,  and  the  child  is  of  a  delicate  or  rickety  constitution, 
or  if  there  is  great  debility,  then  it  must  be  viewed  in  an  unfavor- 
able light. 

*   Vide  Chapter  XLI,  On  Pericarditis. 

t  Principles  and  Practice  of  Medicine,  by  Sir  T.  Watson,  Bart.,  1857,  vol.  ii,  p.  123. 

28 


434  DISEASES   OF   CHILDRE^ST. 

Morbid.  Anatomy. — In  the  first  stage  of  pleurisy  tlie  pleura  is 
drier  than  in  health  ;  its  smoothness  and  transparency  are  dimin- 
ished, and  its  surface  is  more  or  less  vascular,  and  covered  veith 
fLocculi  of  Ijmiph.  In  the  next  stage,  or  that  of  effusion,  a  vari- 
able quantity  of  serum  ma}'  be  present  in  the  pleural  sac,  either 
very  transparent,  or  of  a  pale  lemon-color,  or  it  is  sero-purulent 
with  loose  flakes  of  lymph.  In  exceptional  cases  the  fluid  is  of  a 
reddish  tint,  due  to  the  presence  of  blood  thrown  out  by  the  vas- 
cular membrane.  Layers  of  thick  lymph  may  also  in  some  cases 
be  seen  deposited  on  the  surface  of  the  lung,  gluing  it  to  the  costal 
pleura,  and  preventing  the  movement  which  normally  takes  place 
between  them.  It  is  certain  that  the  character  of  the  exudation 
varies  from  tiriae  to  time,  according  to  the  health  of  the  patient 
and  the  changes  that  take  place  in  the  afiected  membrane.  It  may 
be  serous  at  first,  and  then  become  sero-purulent,  or  even  purulent. 
Post-mortem  evidence  of  pleurisy  without  pneumonia  has  been 
detected  in  the  youngest  children.  The  case  of  an  infant  a  few 
days  old  at  the  Paris  Foundling  Hospital  is  alluded  to  by  Dr. 
Barlow,  where  two  ounces  of  sero-sanguinolent  pus  were  found  in 
the  left  pleura,  etc.  Of  fourteen  cases  of  pleural  eftusion  under 
his  care,  between  the  ages  of  eleven  months  and  two  years,  "  eleven 
were  purulent,  two  were  serous,  and  one  was  serous  with  thick 
lymph."* 

Compression  of  the  lung  depends  on  the  extent  of  eff'usion.  If 
slight  it  only  aftects  the  lower  lobe ;  but  if  the  cavity  be  nearly 
full  of  fluid,  and  it  has  been  collecting  for  some  time,  then  it  will 
squeeze  the  lung  against  the  vertebral  column,  and  increase  the 
dimensions  of  the  chest.  In  a  case  of  thoracentesis  recorded  by 
Dr.  Sansom,  the  lung  of  a  child  twelve  years  of  age  was  reduced 
to  the  size  of  a  small  lemon,  and  the  pleura  was  thickened  and 
ulcerated. t  The  diaphragm  and  liver  may  also  be  pushed  down- 
wards, and  the  heart  displaced. 

In  the  stage  of  absorption  the  exudation  that  has  been  thrown 
out  disappears,  and  the  two  layers  of  the  pleurae  unite  together  by 
means  of  the  lymph,  which  becomes  changed  from  a  soft  structure 
into  a  fibro-cellulav  membrane  of  variable  consistency,  in  some 
cases  firmly  uniting  the  ribs  to  the  pulmonary  pleura,  and  in 
others  leaving  a  distinct  space  between  the  points  of  attachment. 

*  On  Frequency  of  Pleural  Effusion  in  Infancy,  Lancet,  1878,  vol.  ii,  p.  877. 
t  Med.  Times  and  Gaz.,  December  18th,  1875. 


PLEURISY.  435 

As  the  upper  part  of  the  chest-wall  is  in  closer  contact  with  the 
lung  than  the  lower  part,  adhesion  is  more  common  in  this  situa- 
tion ;  whilst  in  the  latter  the  efiusion  gravitates  to  the  lowest 
part  of  the  pleural  cavity,  and  the  ribs  act  with  greater  activity. 

Treatment. — On  our  knowledge  of  the  exact  pathology  of  each 
case  must  rest  fundamentally  our  line  of  treatment.  In  most  cases 
a  large  jacket  poultice  applied  to  the  side  will  relieve  the  pain  and 
relax  the  inflamed  tissues,  without  the  necessity  of  abstracting 
blood. 

Still  I  am  of  opinion  that  when  the  disease  attacks  a  strong  and 
health}'  child,  and  he  is  seen  at  an  early  stage,  when  the  pulse  is 
good,  and  the  pain  in  the  side  is  severe,  three  or  four  leeches  applied 
to  the  painful  part  will  be  likely  to  arrest  the  inflammation,  and 
favor  resolution ;  whereas,  if  depletion  is  neglected  the  disease 
may  run  into  eti'usion  or  suppuration,  and  recovery  be  difficult  and 
protracted.  In  a  few  cases  I  have  employed  leeching  with  advan- 
tage, and  I  do  not  hesitate  to  adopt  it,  as  I  would  in  some  cases 
of  pneumonia  when  the  inflammation  runs  high,  and  the  constitu- 
tion is  strong.  When  pyrexia  and  pain  are  felt  from  the  com- 
mencement of  an  acute  effusive  pleurisy,  Dr.  Clifford  Allbutt 
recommends  leeching,  followed  by  a  saline  diaphoretic.  "  At  the 
outset,  that  is,  within  twenty-four  or  forty-eight  hours,  at  farthest, 
leeches  should  be  applied  liberally  to  the  parts,  according  to  the 
forces  of  the  patient,  and  a  poultice  applied  to  receive  the  bleed- 
ing. As  soon  as  the  bleeding  has  ceased,  the  affected  side  should 
be  bound  down  by  strapping,  after  the  manner  best  described  by 
Dr.  Roberts."* 

At  the  commencement  of  the  disease,  when  the  vessels  are  first 
overloaded  and  engorged,  a  small  dose  of  antimony,  given  every 
four  hours  with  the  solution  of  acetate  of  ammonia,  and  two  or 
three  minims  of  laudanum  (according  to  the  age  of  the  child\  will 
lower  the  pulse  and  promote  diaphoresis.  But  antimony  is  far  less 
beneficial  in  pleurisy  than  in  pneumonia;  and  unless  the  case  is 
complicated  with  the  latter  affection,  it  is  quite  secondary  to 
calomel  and  opium.  Nevertheless,  free  sweating  wonderfully  re- 
lieves the  pain,  and  the  remedy  is  well  calculated  to  cut  short  the 
high  inflammatory  fever  in  a  robust  constitution.  Calomel,  with 
two  or  three  grains  of  Dover's  powder,  is  a  good  combination  ;  and 

*  On  the  Treatment  of  Pleuritic  Effusion,  Brit.  Med.  Journ.,  vol.  ii,  1877,  p.  726. 


436  DISEASES   OF    CHILD  REX. 

if  there  is  not  much  pain  the  mercurial  may  be  given  with  nitrate 
of  potash  and  James's  powder.     (Form.  62.) 

An  active  purgative  dose  ought  to  be  given  at  the  commence- 
ment of  the  disease  to  open  the  bowels,  if  the  pain  is  not  acute 
enough  to  be  increased  by  the  muscular  exertion  which  it  involves. 
"When  the  pain  is  severe,  our  first  step  should  be  if  possible  to 
arrest  it,  because  its  continuance  prevents  sleep,  and  is  more  ex- 
hausting than  any  dej)leting  measures.  It  should  be  an  axiom  to 
remove  pain  at  once.  "  Of  medicines,"  says  Dr.  Allbutt,  "  I  advise 
a  mild  saline  purgative  at  the  beginning,  by  the  use  of  mercury 
and  chalk  combined  with  the  use  of  Dover's  powder  in  fractional 
doses,  or  in  weakl}^  patients  by  the  use  of  Dover's  powder  alone. 
Between  these  powders  I  give  a  mixture  containing  acetate  of 
potash  and  large  doses  of  liquor  ammonise  acetatis.  By  this 
method  I  obtain  far  better  results  than  were  wont  to  follow  my 
expectant  treatment  of  former  years.  The  fibrinous  efiusion  which 
issues  in  these  cases  almost  always  subsides  when  it  has  reached 
its  height,  and,  if  this  height  be  the  height  of  the  spine  of  the 
scapula  and  the  fourth  rib,  I  am  for  this  reason  never  in  haste  to 
interfere  by  operation  so  long  as  the  patient  breathes  in  tolerable 
comfort  and  the  other  lung  is  well  at  work.  On  the  other  hand, 
if  the  jDatient  be  uneasy,  or  if  the  entry  of  blood  to  the  right  heart 
be  hindered,  I  do  not  hesitate  to  tap  it  at  once.  The  favorable 
aspects  of  operation  in  such  cases  is  that  suppurative  conversion 
rarely  occurs  in  these  highl}^  organized  eff'usions,  even  if  air  enters 
the  pleura."* 

When  the  acute  symptoms  have  subsided  and  all  fever  has 
departed,  counter-irritation  to  the  affected  side,  in  the  shape  of 
blisters,  with  the  perchloride  of  mercury  and  bark,  will  get  rid  of 
any  fluid  that  may  remain.  But  a  blister  should  not  be  applied 
till  the  chronic  stage  is  reached  and  the  pain  is  diminishing. 
Then  it  does  not  increase  the  local  mischief,  whilst  it  promotes 
the  absorption  of  any  fluid  that  may  be  present.  A  succession 
of  flj'ing  blisters  is  preferable  to  one  allowed  to  remain  long 
enough  to  cause  troublesome  vesication  and  soreness.  For  it 
should  be  remembered  that  obstinate  sores  and  great  weakness  are 
prone  to  follow  their  use  in  young  children.  They  should  not, 
therefore,  be  employed  without  carefully  considering  the  grave 
results  that  may  ensue. 

*  On  the  Treatment  of  Pleuritic  Effusion,  Brit.  Med.  Journ.,  vol.  ii,  1877,  p.  726. 


PLEURISY.  437 

The  diet  in  acute  pleurisy  should  be  strictly  antiphlogistic. 

Chronic  Pleurisy. — The  causes  which  usually  induce  this  condi- 
tion are  the  consequences  of  the  acute  form,  or  of  pleuropneu- 
monia. The  effusion  which  has  taken  place  is  slow  of  absorption, 
or  resists  it  altogether.  If  there  is  fever  and  the  general  health 
is  cachectic  or  much  impaired,  the  effusion  may  become  perma- 
nent, and  no  relief  can  be  afforded  except  by  a  surgical  opera- 
tion. Chronic  pleurisj^,  however,  cannot  always  be  traced  to  the 
acute  form.  It  sometimes  steals  on  imperceptibly  in  delicate 
children,  and  is  only  ascertained  when  a  careful  examination  of  the 
chest  reveals  the  cause  of  the  chronic  cougli  and  breathlessness. 
It  may  attend  the  dropsy  which  follows  scarlatina  and  renal  dis- 
ease, or  the  antemia  of  strumous  and  badly-fed  children.  It  may 
also  arise  from  the  irritation  of  tubercle  exciting  a  low  fomi  of 
inflammation  in  the  pleura  and  leading  to  copious  effusion.  In 
these  last-mentioned  instances  the  disease  is  of  a  subacute  or  latent 
form. 

Pleuritic  effusion  is  most  frequently  met  with  on  the  left  side 
of  the  thorax ;  and  the  more  serous  the  fluid  the  more  readily  is 
it  absorbed.  When  purulent  or  sero-purulent,  it  disappears  very 
slowly. 

The  signs  that  follow  the  effusion  of  fluid  in  the  pleural  cavity 
in  the  chronic  state  are  similar  to  those  of  the  acute.  There  are 
universal  dulness  on  percussion  and  an  absence  of  vocal  vibration  ; 
normal  respiration  is  replaced  by  bronchial  or  tubular  breathing, 
or  it  may  be  entirely  absent,  and  dyspnoea,  accelerated  pulse,  fail- 
ing health,  and  loss  of  flesh  are  to  be  noted.  In  some  cases  there 
is  hectic  fever.  The  breathing  is  not  always  difficult  in  the  ab- 
sence of  tubercle.  The  eflusion  may  be  considerable,  and  the  lung 
on  the  aflected  side  maybe  prevented  from  expanding;  and  3'et 
the  breathing  may  be  tranquil  and  cough  absent,  when  one  lung  is 
sound  and  healthy.  More  particularly  is  this  the  case  when  the 
effusion  has  been  gradual  and  the  function  of  the  lung  diminished 
by  degrees.  And  it  should  also  be  borne  in  mind  that  a  small 
effusion  may  act  as  an  irritant  and  cause  much  embarrassment  in 
respiration,  when  a  larger  eft'usion  has  no  such  effect.  If  the  effu- 
sion is  copious,  and  has  lasted  for  some  time,  the  functions  of  the 
lung  become  gradually  impaired  or  even  lost  altogether.  Both  air 
and  blood  are  forced  out  of  the  pulmonary  tissue  by  the  compres- 
sion to  which  it  is  subjected ;  and  hence  the  lung,  in  long-standing 


438  DISEASES    OF   CHILDREN. 

cases  of  effusion,  becomes  flattened,  tongb,  and  contracted.  It 
never  completely  re-expands,  and  therefore  when  the  fluid  is  re- 
absorbed the  chest  falls  in,  the  sternum  is  flattened,  the  diameter 
of  the  chest  is  diminished,  and  the  spine  is  curved.  The  pleura 
becomes  much  thickened,  and  in  some  cases  ulcerated.  The  mus- 
cles are  more  or  less  wasted,  the  patient  walks  much  less  erect, 
and  leans  towards  the  affected  side.  The  puerile  respiration  in  the  ' 
sound  lung,  which  has  been  recognized  during  the  effusive  stage, 
leads  to  more  or  less  enlargement  of  the  air-cells  and  dilatation  of 
the  bronchial  tubes. 

When  the  effusion  into  the  left  pleural  sac  is  considerable,  the 
apex  beat  can  be  sometimes  felt  to  the  right  of  the  sternum.  "  I 
-have  observed  that  in  children  there  is,  as  a  rule,  less  visceral  dis- 
location than  in  adults.  The  diaphragm  is  not  so  often  driven 
downwards,  nor  is  the  heart  thrust  away  so  frequently  from  its 
position.  Their  yielding  chest-walls  expand,  and  percussion  dis- 
covers but  occasionally  that  the  heart  or  liver  is  displaced."*  In 
chronic  pleurisy,  with  extensive  effusion,  the  patient  cannot  lie  on 
the  sound  side.  It  is  said  by  some  authorities  that  syncope  and 
irregularity  of  the  heart's  action  are  more  common  when  the  effu- 
sion is  on  the  left  than  on  the  right  side.  This  seems  quite  pos- 
sible, for  the  fibrous  adhesions  which  bind  the  lung  to  the  spine 
may  limit  the  heart's  movements.  "  Such  bands  also,  though  less 
frequentlj^,  fasten  the  pericardium  in  an  unnatural  position,  by 
which  the  action  of  the  heart  is  hindered. "f 

The  treatment  of  chronic  pleurisy  is  altogether  different  from 
that  of  the  acute  form.  In  the  former  the  diet  must  be  more 
liberal,  and  good  food  and  wine  will  in  some  cases  be  needed.  It 
may  be  necessary  to  apply  a  blister  from  time  to  time,  followed 
by  the  application  of  iodine.  The  aflected  side  of  the  chest  should 
be  painted  with  tincture  of  iodine,  diluted  with  water  (one  in 
seven),  night  and  morning,  and  then  covered  with  two  folds  of 
flannel  and  calico  like  a  half  waistcoat  in  shape.  This  practice 
was  first  advocated  by  Dr.  Fuller. 

Iodide  of  potassium  with  bark,  or  small  doses  of  perchloride  of 
mercury,  squill,  digitalis,  or  acetate  of  potash  may  be  administered. 
When  the  urine  is  scanty  or  high-colored,  and  the  eft'usion  is  of  a 

*  On  Pleuritic  Effusions,  by  Dr.  Wardcll,  Brit.  Med.  Journ.,  1874. 
t  On  Tapping  and  Draining  tlie  Pleura,  by  Berkeley  Hill,  F.K.C.S.,  The  Lancet, 
vol.  ii,  1875,  p.  87. 


PLEURISY.  439 

chronic  or  half  inflammatory  character,  diuretic  remedies  are  of 
value.  Dr.  Gairdner  speaks  highly  of  cream  of  tartar  electuary 
in  acute  and  chronic  cases  of  eflusion,  which  not  only  stimulates 
the  kidneys,  hut  keeps  the  bowels  freely  open,  if  they  are  not 
already  so.  It  consists  of  cream  of  tartar,  mixed  with  equal  parts 
of  honey,  treacle,  or  marmalade,  and  of  this  a  small  teaspoonful 
or  more  may  be  given  according  to  the  age  of  the  patient* 

If  the  child  is  weak  and  anfemic  we  must  have  recourse  to 
tonics  in  order  to  maintain  the  general  strength  and  to  promote 
the  absorption  of  the  fluid.  Among  them  the  preparation  of 
quinine  and  iron  are  invaluable,  given  alone  or  in  a  combination. 
If  the  kidneys  are  sluggish  in  their  action,  and  the  tongue  is 
clean,  the  tincture  of  the  perchloride  of  iron  will  prove  one  of  the 
best  of  remedies.  The  syrup  of  the  iodide  of  iron,  the  syrup- of 
the4:)hosphate  of  iron,  and  the  soluble  dialyzed  iron  will  furnish 
good  results  in  some  instances.  The  mineral  acids  (Form.  14,  20, 
21),  liquor  strychnine,  with  phosphoric  acid,  and  the  tincture  of 
bark,  are  likewise  indicated  in  special  cases.  Cod-liver  oil  should 
be  given  in  all  chronic  cases.  The  skin  should  be  kept  in  a 
healthy  state  by  an  occasional  bath,  and  even  friction  over  the 
affected  side  will  in  some  degree  assist  in  favoring  absorption. 
Above  all,  the  actiun  of  the  liver  and  bowels  should  be  efficiently 
maintained,  so  that  a  free  elimination  of  morbid  matters  may 
take  place  through  the  chief  excretory  organs. 

When  the  health  is  sound  and  vigorous  and  the  eflfusion  is  of  a 
serous  character,  every  opportunity  ought  to  be  given  to  promote 
absorption  of  the  fluid  before  resorting  to  thoracentesis. 

Einjyyema. — This  is  extremely  frequent  in  children. f  "When 
the  efl:usion  resulting  from  chronic  pleurisy  remains  unabsorbed 
and  there  is  pyrexia,  we  may  suspect  that  it  has  become  purulent, 
more  especially  if  there  are  in  addition  delirium  or  profuse  perspi- 
ration. The  fluid  becomes  transformed  into  pus  much  quicker  in 
some  cases  than  in  others,  but  no  exact  time  can  be  stated  with 
accuracy.  It  remains  serous  in  some  instances  for  weeks  together, 
and  in  others  it  is  purulent  from  an  early  date,  probably  at  the 

*  Clinical  Medicine,  1872,  p.  297. 

t  "  Out  of  forty-four  consecutive  cases  of  pleurisy  admitted  as  in-patients  at  Great 
Orraond  Street,  twenty-seven  were  empyemata.  Taking  another  series  of  sixteen 
cases,  fourteen  were  empyemata." — Notes  on  Pleuritic  Effusion  in  Childhood,  by  T. 
Barlow,  M.D.,  and  R.  W.  Parker,  Brit.  Med.  Journ.,  vol.  ii,  1877,  p.  759. 


440  DISEASES    OF    CHILDREX. 

end  of  a  week  or  two.  Empj-eraa  rarely  springs  from  tubercle. 
Whether  there  be  a  simple  serous  effusion,  or  pus,  the  symptoms 
are  very  similar — there  is  dj'spnoea,  increased  by  lying  down  or 
walking,  a  sense  of  constriction  or  discomfort  in  the  chest,  and 
dry  and  frequent  cough  with  or  without  expectoration.  Generally 
the  face  is  anxious,  or  pale,  or  dusky,  the  pulse  quick  and  weak, 
and  the  pulsations  of  the  heart  readily  affected  in  force  and  fre- 
quency by  trilling  causes. 

The  physical  signs  are  th^  same  as  those  met  with  in  pleural 
effusion,  except  that  there  is  usuallj'  more  bulging  of  the  intercostal 
spaces.  Dr.  Wilks  says,  that  if  after  an  inflammator}^  attack  in 
the  chest,  whether  of  acute  pleurisy  or  of  pleuropneumonia, 
"there  result  localized  dulness,  with  absence  of  breath-sound,  and 
perhaps  distant  tubular,  breathing,  an  empyema  may  be  safely 
suspected  ;"*  but  I  think  this  testimony  must  be  received  with 
caution,  even  from  so  high  an  authority.  "It  has  appeared  to  us 
that  the  aspect  of  the  patient — a  peculiar  anjemia,  with  an  earthy 
complexion,  and,  above  all,  clubbing  of  the  finger  ends,  have  been 
the  most  characteristic  features,  suggesting  empyema,  rather  than 
serous  effusion."!  If  the  effusion  is  only  moderate  and  not  of 
sufficient  standing  to  seriously  impair  the  resiliency  of  the  lung, 
then,  as  in  the  serous  form,  the  dulness  will  vary  with  the  position 
of  the  patient,  and  if  he  be  made  to  lie  on  the  uuaft'ected  side,  the 
part  of  the  thorax  which  before  was  dull  may  become  resonant  in 
consequence  of  the  fluid  gravitating  to  the  lowest  part  of  the 
pleural  cavity.  "  When  the  liquid  has  for  a  long  time  been  eflused, 
the  intercostal  muscles,  from  having  been  continuously  stretched, 
lose  their  contractile  power,  become  paralyzed,  flat,  and  then  even 
tend  to  protrude.  Albertini  supposed,  and  Stokes  believed,  that 
such  a  state  denoted  pus.":}: 

Of  all  the  diagnostic  signs  of  fluid  in  the  chest,  whether  serous 
or  purulent,  the  dull  heavy  thud  which  percussion  elicits  is  the 
most  certain.  Whenever  fluid  in  any  quantity  is  collected  no  reso- 
nance can  be  produced ;  this  resonance  extends  to  the  limits  of  the 


*  Local  Empyema ;  its  Diagnosis  and  Treatment,  Brit.  Med.  Journ.,  vol.  i,  1879,  p. 
528. 

f  Notes  on  Pleuritic  Effusion  in  Childhood,  by  T.  Barlow,  M.D.,  and  R.  W.  Parker, 
Brit.  Med.  Journ.,  1877,  vol.  ii,  p.  759. 

X  On  Pleuritic  Effusion,  by  R.  Wardell,  M.D.,  Brit.  Med.  Journ.,  1874, 


PLEURISY.  441 

effusion,  varying  with  the  position  of  the  trunk,  unless  the  pleurae 
have  become  thickened  and  adhesions  formed  between  them. 

It  is  said  that  patients  cannot  lie  on  the  f^ound  side,  nor  indeed 
on  the  other;  but  I  have  known  them  assume  any  position  in  bed 
with  considerable  fluid  in  the  pleura,  either  serous  or  purulent, 
without  any  oppression  in  breathing.  The  absence  of  this  symp- 
tom, therefore,  must  not  be  relied  on  as  evidence  that  no  effusion 
exists,  and  the  chest  in  consequence  overlooked. 

A  case  of  empyema  came  under  my  notice  in  a  girl,  five  years 
of  age,  who  w^as  admitted  into  the  Samaritan  Hospital,  March 
12th,  1878,  under  the  care  of  Dr.  Wynn  Williams.  She  was  pale, 
thin,  and  delicate,  with  the  fingers  much  clubbed.  The  pulse  w^as 
weak  and  accelerated,  but  the  temperature  was  normal.  The  res- 
pirations were  twenty-eight  per  minute.  It  was  stated  that  she 
had  had  inflammation  of  the  chest  for  thirteen  weeks,  and  that 
two  months  before  admission  an  abscess  had  been  opened,  external 
and  two  inches  below  the  left  nipple,  leaving  a  sinus  surrounded 
by  a  large  granular  flabby  ulcer.  Matter  was  discharged,  and  it 
continued  to  drain  away  till  her  admission. 

On  examination  the  left  or  affected  side  of  the  chest  was  found 
to  be  flattened ;  it  measured  ten  inches  from  the  spine  to  the  centre 
of  the  sternum;  the  right  side  was  more  rounded,  and  measured 
ten  and  a  half  inches.  Below  the  left  clavicle  the  flattening  was 
very  perceptible,  dulness  was  great,  and  no  air  entered  the  lung. 
The  left  side  of  the  thorax  was  immovable  on  inspiration.  Through 
the  sinus  laudable  pus  was  discharged,  and  for  two  inches  around 
it  the  percussion-note  was  tympanitic  when  she  turned  on  the  right 
side,  because  the  pus  gravitated  to  the  bottom  of  the  pleural  cavity, 
which  now  contained  air.  The  respiration  w-as  exaggerated  over 
the  whole  right  thorax.  Posteriorly  the  percussion-note  was  clear 
throughout  the  right  lung.  In  the  left  suprascapular  space  it  was 
very  dull,  and  respiration  w^as  weak  and  bronchophonic  through- 
out; there  was  diminished  resonance  betw^een  the  spine  and  the 
scapula  on  the  left  side.  'No  respiration  could  be  heard  in  the  left 
axillary  region.  The  heart's  sounds  were  normal  and  very  distinct. 
The  apex-beat  was  seen  for  an  inch  to  the  right  side  of  the  left 
nipple.  There  was  short  dry  cough,  but  the  appetite  was  good, 
and  there  was  no  sweating. 

On  March  22d  an  opening  was  made  below  the  angle  of  the  left 
scapula,  and  about  an  ounce  of  pus  drained  away  through  a  piece 


442  DISEASES    OF   CHILDEEN. 

of  india-rubber  tubing.  On  the  following  evening  tbe  temperature 
rose  to  103.4°,  and  the  pulse  to  134.  On  the  23d  the  temperature 
fell  to  101.0°,  and  two  days  later  it  did  not  exceed  the  normal 
point.  On  the  31st  an  ounce  of  pus  was  drawn  off  through  the 
anterior  opening,  and  a  weak  solution  of  iodine  injected  without 
raising  the  temperature.  The  child  left  the  hosj^ital  after  a  stay 
of  nearly  three  months,  with  the  sinus  still  discharging. 

The  patient  again  presented  herself  at  the  hospital  (August  4th, 
1879)  on  her  return  from  the  Isle  of  Wight,  where  she  had  been 
staying  for  two  months.  In  December,  1878,  an  abscess  which 
had  been  forming  gradually  at  the  centre  of  the  sternum  and  to 
the  left  of  the  median  line  burst,  and  had  been  discharging  a 
quantity  of  thick  yellow  pus  ever  since.  The  two  openings  pre- 
viousl}'  alluded  to  healed  in  Februarj^,  1879.  The  contour  of  the 
thorax  was  much  changed  in  its  appearance,  particularly  laterally 
and  posteriorly.  The  spine  was  much  curved,  chiefly  in  the  dorsal 
region  between  the  scapulee,  the  convexity  being  towards  the  right 
side.  On  the  left  side  the  collapse  of  the  lung  and  the  copious 
discharge  of  pus  from  time  to  time  had  caused  the  ribs  to  fall 
inwards,  and  to  diminish  the  capacity  of  the  thorax,  so  that  the 
infra-axillary  region  was  concave,  and  the  ribs  behind  drawn  in 
below  the  left  scapula,  the  angle  of  which  was  tilted  upwards. 
The  measurements  of  the  two  sides  of  the  thorax  present  a  re- 
markable contrast : 

EigM  side.  Left  side. 

Line  of  nipple  from  centre  of  sternum  to  spine,  .     12  j  inches.  8j  inches. 

Line  of  ensiform  cartilage, 12         "  9         "  . 

Line  of  axilla,      ...         .      '.         .         .        .     llj       "  9         " 

Eelow  the  left  clavicle  the  note  was  dull,  but  some  air  could  be 
heard  to  enter  it ;  posteriorly  there  was  resonance  throughout  the 
left  lung,  and  respiration  was  slowly  being  re-established.  Over 
the  old  cicatrices  air  could  not  be  heard  to  enter  from  adhesions 
which  had  formed  there.  Throag-hout  the  rio-ht  luno;,  both  in 
front  and  behind,  the  note  was  hypor-resonant  and  the  respiration 
puerile.  The  heart  was  thrown  over  to  the  right  side,  and  its 
apex  felt  beating  to  the  right  of  the  ensiform  cartilage.  There 
^w^as  a  distinct  apex  bruit,  which  was  probably  due  to  displacement 
and  pressure,  and  also  to  relaxation  of  the  cavities.  The  murmur 
was  heard  in  the  back.  As  the  pulse  was  quiet  and  the  tempera- 
ture normal,  and  there  was  neither  cough  nor  sweating,  we  may 


PLEURISY.  443 

reasonably  hope  that  the  last  abscess  will  contract  like  the  two 
former  ones,  and  the  patient  eventually  recover  her  health. 

When  the  acute  symptoms  are  of  shorter  duration  the  wound 
may  heal  quickly.  A  little  girl,  aged  ten,  was  admitted  into  the 
London  Hospital,  with  signs  of  effusion  in  the  right  pleura,  point- 
ing beneath  the  nipple,  and  cardiac  displacement  to  the  left.  Al- 
though the  chest  was  aspirated  from  behind,  and  six  ounces  of  pus 
removed,  the  skin  gave  way  below  the  nipple  three  weeks  after 
admission,  and  discharged  freely.  The  wound  healed  completely 
in  two  months,  and  the  right  chest  had  fallen  in.*  We  must  not, 
however,  overlook  the  fact  that  a  fistulous  orifice  in  the  pleura 
may  remain  open  for  years,  and  finally  contract  and  heal  up.  A 
girl  on  whom  Mr.  Berkeley  Hill  operated  for  empyema,  wore  a 
silver  tube  "  from  her  eighth  to  her  thirteenth  year,  during  which 
period  she  had  scarlet  fever."f  The  cure  was  perfect,  leaving  very 
little  coiitraction  over  the  affected  side. 

An  empyema  when  left  to  itself  may  dry  up  and  disappear  by 
absorption.  In  rare  instances  the  pus  may  find  its  way  through 
the  diaphragm  into  the  abdominal  cavity  and  set  up  peritonitis,  or 
it  may  perforate  the  lung-tissue  and  be  discharged  through  the 
bronchus,  even  after  paracentesis,  and  the  child  then  recover.:}:  A 
case  is  recorded  in  which  an  empyema  in  a  girl,  ten  years  of  age, 
burst  into  the  oesophagus. § 

Paracentesis. — The  operation,  if  indicated,  should  be  delayed  till 
the  pyrexia  has  passed  away  and  the  patient  is  in  a  quiescent  state. 
But  the  fact  of  an  elevation  of  two  or  three  degrees  of  tempera- 
ture, fever  being  present,  ought  not  to  stand  in  the  w'ay  of  an 
operation,  if  the  fluid  is  in  such  quantity  as  to  have  resisted  ab- 
sorption, or  if  it  is  purulent.||  In  either  case  the  temperature 
generally  falls  when  the  fluid  is  drawn  oft',  and  the  patient  breathes 

*  Keport  of  the  Medical  Registrar  for  1876,  p.  77. 

t  Op.  cit.,  p.  88. 

t  Brit.  Med.  Journ.,  vol.  i,  1880,  p.  850. 

g  Steiner's  Diseases  of  Children,  1874,  p.  170. 

II  Dr.  Sidney  Ringer  has  recorded  some  cases  of  pleuritic  effusion  in  young  children 
in  which  paracentesis  was  performed  with  immense  relief,  and  with  very  little  disturb- 
ance to  the  general  health.  Dr.  Ringer  says  his  cases  show  that  the  operation  may  be 
performed  during  the  febrile  and  non-febrile  period  of  the  disease,  that  the  fluid  may 
be  withdrawn  by  the  aspirator  during  the  fever,  without  any  reaccumulation  ;  that  in 
some  cases  of  febrile  and  non-febrile  empyema,  a  part  of  the  pus  rbay  be  withdrawn 
by  the  aspirator,  and  the  rest  disappear.  They  further  show  that  in  severe  empyema 
the  temperature  may  be  normal,  or  nearly  so.     (Practitioner,  1873,  vol.  ii,  p.  408.) 


444  BLSEASES    OF    CHILDREN. 

more  easily,  and  is  in  all  respects  better.  The  indications  which 
appear  to  justify  thoracentesis  are  failure  in  the  process  of  absorp- 
tion, so  that  the  fluid  remains  compressing  th^  lung,  and  causing 
urgent  dj-spnosa,  irregular  pulse,  and  feebleness  of  the  heart's 
action  ;  or  when  the  fluid  becomes  fetid,  and  produces  such  consti- 
tutional disturbance  that  the  patient  is  in  danger  of  dying  from 
hectic  fever  and  septic  poisoning. 

A  case  of  pleuritic  eftusion,  probably  unique  from  the  tender  age 
of  the  patient  and  the  operation  of  paracentesis,  is  recorded  by 
Dr.  Cayley,  where  a  well-grown  male  infant,  fed  at  the  breast, 
suftered  from  cough  and  difficulty  of  breathing  of  one  week's  du- 
ration before  any  relief  was  sought.  When  seen  by  Dr.  Cayley 
(Oct.  22d,  1878)  there  was  extreuie  dyspnoea  and  rapid  respirations, 
tossing  of  the  arms  about,  and  throwing  back  of  the  head.  "  There 
was  a  frequent  short  abortive  cough."  The  whole  of  the  left  lung 
was  dull  on  percussion,  and  there  was  an  absence  of  breath-sounds. 
The  heart's  apex  beat  to  the  right  of  the  sternum.  Paracentesis 
was  performed  below  the  angle  of  the  scapula  by  means  of  a  trocar 
and  canula,  and  "  eight  ounces  of  turbid  serum  were  drawn  ofi:'by 
a  bell-jar  aspirator."  A  fortnight  after  the  operation  there  was 
still  cough,  but  the  child  appeared  well.  There  was  impaired 
resonance  at  the  left  base,  and  the  breathing  was  tubular, — symp- 
toms not  unlike  a  refilling  of  the  pleural  cavity.* 

After  paracentesis,  when  serum  only  is  evacuated,  any  fluid  that 
remains  behind  may  become  purulent  and  the  patient  may  die.  As 
long  as  the  fluid  is  simply  serum  every  chance  should  be  given  to 
the  persevering  use  of  blisters,  iodine,  and  other  local  remedies  ; 
but  when  it  is  purulent,  which  can  only  be  jD^sitively  ascertained 
by  passing  a  grooved  needle,  or  still  better,  a  hj^podermic  syringe, 
through  an  intercostal  space,  the  sooner  it  is  got  rid  of  the  better. 
It  is  nothing  more  nor  less  than  an  abscess,  and  must  be  dealt  with 
aecordingl3\  When  pus  is  drawn  oft'  by  tapping,  recovery  is  in- 
variably slow,  because  the  extensive  area  of  the  pleural  membrane 
is  in  a  state  of  chronic  inflammation,  and  the  lung  may  be  bound 
down  through  thickening  and  the  formation  of  false  membrane. 

The  operation  having  been  decided  upon,  an  ansesthetic  should 
be  administered,  in  order  to  keep  the  patient  quiet  and  to  abolish 
pain.     I  have  administered  the  bichloride  of  methylene  in  several 

*  "  Pleurisy  with  Effu.sion  in  an  Infant  four  montlis  old^  Paracentesis,  Recovery," — 
Lancet,  vol.  ii,  1878,  p.  807. 


PLEURISY.  445 

cases,  without  inducing  the  slightest  danger,  the  pulse  often  im- 
proving under  its  administration.  Every  child  should  he  anesthet- 
ized whose  chest  requires  tapping.  The  danger  arising  from  it  is 
practically  nil  if  carefully  administered,  and  infinitely  less  than 
would  follow  the  tedious  and  painful  operation  of  puncturing  the 
chest-wall  during  consciousness,  at  a  time  when  the  child  is 
already  weakened  and  terrified.  Antiseptic  precautions  are  to  be 
adopted. 

If  the  eftusion  be  on  the  left  side  it  is  customary  to  make  an 
opening  in  the  fifth  intercostal  space,  if  on  the  right  side  in  the 
fourth  intercostal  space,  midway  between  the  sjDine  and  the  ster- 
num (infra-axillary  region),  then  to  introduce  a  probe  and  to  pass 
it  downwards  to  the  lower  part  of  the  pleural  cavity  above  the 
diaphragm.  The  point  having  been  felt  beneath  the  skin  an 
opening  is  made  upon  it,  and  a  drainage-tube  is  pulled  through, 
and  the  two  ends  united.  Simple  tapping  may  be  had  recourse  to 
if  the  effusion  is  serous,  and  the  operation  may  be  repeated  from 
time  to  time,  so  as  to  give  the  cavity  a  chance  of  contracting,  and 
the  lung  of  expanding.  This  has  happened  in  some  cases.  But 
if  the  collection  be  purulent  a  permanent  drainage  must  be  estab- 
lished. 

Another  plan,  recommended  by  Mr.  Howard  Marsh,  is  to  pro- 
cure a  jSTo.  3  catheter,  and  by  means  of  a  silver  wire  to  push  "from 
the  eye  to  the  handle  end"  a  strong  silk  ligature,  hanging  out  at 
either  end.  The  catheter  is  introduced  through  the  upper  open- 
ing, and  its  point  is  directed  to  an  intercostal  space  at  the  lowest 
part  of  the  pleural  cavity.  An  incision  is  made  upon  it,  the  silk 
seized  and  held  firmly  while  the  catheter  is  drawn  out  of  it  as  it 
was  introduced,  and  a  drainage-tube  being  attached  to  the  silk  it 
is  drawn  through  the  two  openings.* 

When  the  fluid  drawn  ofFby  the  aspirator  or  hypodermic  syrino-e 
is  purulent,  and  there  is  accumulation  from  time  to  time,  a  per- 
manent orifice  should  be  maintained  by  means  of  a  double  opening, 
one  anteriorly,  and  the  other  below  the  angle  of  the  scapula, 
through  wdiich  a  piece  of  drainage-tube  is  passed,  and  secured  at 
both  ends  in  the  manner  previously  described. 

During  the  operation  the  admission  of  air  into  the  pleural  sac 
should  be  carefutly  guarded  against  lest  it  produce  suppuration  in 
the  sac,  "  still  there  is  a  considerable  body  of  evidence  to  show 

*  The  Surgical  Treatment  of  Empyema,  Brit.  Med.  Journ.,  1877,  vol.  ii,  p.  887. 


446  DISEASES   OF   CHILDREN. 

that  the  admission  of  air  to  the  cavity  of  the  thorax,  when  serous 
effusion  exists,  does  not  necessarili/ indMCQ  purulence.  I  may,  how- 
ever, remark  that  such  an  accident  should  be  regarded  as  danger- 
ous ;  hut  it  is  a  danger  not  always  easy  to  avoid,  and  it  should  he 
taken  seriouslj-  into  account  among  the  risks  of  the  operation,"* 
Dr.  Markham  Skerritt  prefers  the  use  of  an  aspirator,  as  air  is  thus 
kept  out  of  the  pleural  cavity .f  The  best  form  of  aspirator  is  that 
in  which  a  special  receiver  is  dispensed  with,  the  tube  of  the  as- 
pirator being  set  in  a  plug  of  vulcanite  india-rubber  ;  this  can  then 
be  fitted  into  the  neck  of  any  ordinary  bottle.  This  convenient 
modification  of  the  aspirator  was  introduced  by  Professor  Wood. 
But  whatever  instrument  we  employ,  it  is  certain  that  Lister's 
antiseptic  method  properly  carried  out  renders  the  adnnission  of  air 
comparatively  harmless,  Mr.  Berkeley  Hill  says,  "  You  need  not 
aspirate  at  all  in  most  cases ;  the  pressure  within  the  chest  will 
drive  out  the  fluid  fast  enough,  though  the  syringe  is  useful  to 
force  back  a  clot,  or  shred  of  lymph,  if  such  block  the  tube,":}: 

The  physical  and  general  symptoms  which  justify  the  operation 
of  paracentesis  may  be  thus  classified. 

1.  When  the  effusion  has  become  chronic,  the  pyrexia  has  sub- 
sided, and  the  health  is  perceptibly  declining.  Under  these  cir- 
cumstances death  may  take  place  from  suffocation  or  syncope. 

2.  When  the  effusion  is  so  large  that  the  lung  is  compressed  and 
incapable  of  expanding.  This  can  usually  be  ascertained  by  dul- 
ness  on  percussion  and  the  absence  of  respiration,  by  obliteration 
or  bulging  of  the  intercostal  spaces,  and  occasional  increase  in  the 
dimensions  of  the  side, 

3.  When  the  heart  is  displaced  by  effusion,  or  the  liver  and 
Bpleen  pushed  downwards,  and  there  is  irregularity  of  the  pulse 
and  dyspncea, 

4.  When  the  effusion  remains  copious  after  the  assiduous 
employment  of  constitutional  and  local  remedies,  and  especially  if 
pus  follow  the  introduction  of  a  grooved  needle  into  the  pleural 
cavity. 

5.  The  longer  the  fluid  is  allowed  to  remain  in  the  pleural  cavity 
the  more  likely  is  it  to  undergo  pathological  changes  and  to  resist 
absorption. 

*  On  the  Mortality  of  Pleurisy,  considered  in  relation  to  the  Operation  of  Para- 
centesis Thoracis,  by  Dr.  Wilson  Fox,  Brit.  Med.  Journ.,  1877,  p.  725. 
t  Treatment  of  Pleuritic  Effusion,  Erit.  Med.  Journ.,  1879,  vol.  ii,  p.  54. 
X  Op.  cit.,  p.  88, 


PLEURISY.  447 

6,  Fluid  may  be  drawn  oft'  as  it  forms  from  time  to  time,  lest 
adhesions  ensue,  and  the  lung  never  completely  re-expand.  "  Con- 
trary to  what  was  once  alleged,  repeated  puncture  is  more  likely 
to  prevent  the  conversion  of  serum  into  pus  than  to  hasten  it."* 
The  partial  evacuation  of  an  empyema  may  be  followed  by  the 
drying  up  of  the  rest. 

7,  "When  the  functions  of  one  lung  are  impaired  by  the  mechani- 
cal pressure  of  the  fluid  and  there  is  bronchitis  or  pneumonia  in 
the  other. 

8,  A  certain  degree  of  fever  does  not  contraindicate  the  opera- 
tion, nor  does  it  necessarily  increase  the  local  changes.  After 
tapping,  the  fever  generally  falls  ;  and  even  if  hectic  fever  is 
present,  the  free  escape  of  pus  through  a  good-sized  opening  in 
the  most  dependent  part  of  the  chest-wall  will  sometimes  arrest  it 
entirely. 

With  regard  to  injections  of  iodine  into  the  pleural  sac,  I  have 
known  considerable  fever  and  pain  follow  their  use  in  the  most 
diluted  form.  When  there  is  a  copious  secretion  of  offensive  pus 
keeping  up  the  febrile  state,  a  weak  solution  of  carbolic  acid,  in- 
troduced through  a  flexible  catheter,  appears  to  be  highly  advan- 
tageous. Dr.  D.  M.  Williams  washed  out  the  pleural  cavity  for 
thirty-one  days  with  a  weak  solution  of  sulphurous  acid,  and  a 
good  result  followed  f 

In  long-standing  cases  of  empyema  the  chest  may  be  contracted 
and  the  ribs  approximate,  so  as  to  produce  great  deformity,  and 
yet  the  pleural  cavity  may  be  full  of  fluid,  and  the  diaphragm  be 
pressed  downwards. 

Empyema  may  exist  with  pneumothorax,  air  having  found  its 
way  into  the  cavity  of  the  chest  through  the  pleura  lining  the 
lung,  or  the  interior  of  the  chest.  A  singular  case  is  recorded 
by  Dr.  Cheadle,  in  which  a  boy,  ten  years  of  age,  who  was  ad- 
mitted into  the  Hospital  for  Sick  Children,  April  18th,  1877,  had 
effusion  in  the  right  pleura  with  displacement  of  the  heart's  apex. 
The  temperature  oscillated  between  99.5°  and  102°.  Between  the 
time  of  his  admission  and  the  August  following  he  was  tapped 
four  times.  On  the  last  occasion  twenty-six  ounces  of  thick  pus 
were  removed.  There  were  fever  and  sweating,  soon  followed  by 
phlebitis  in  the  right  leg,  and  slight  albuminuria.  In  September 
a  counter-opening  was  made  in  the  chest,  a  drainage-tube  in- 

*  Berkeley  Hill,  op.  cit.,  p.  88.  t  Practitioner,  1878,  p.  125. 


448  DISEASES   OF   CHILDREN. 

serted,  and  the  cavity  of  the  pleura  syringed  out  with  carbolic 
acid  lotion.  Three  days  before  death  the  respirations  became 
rapid,  face  blue,  cardiac  resonance,  and  amphoric  breathing  over 
the  left  nipple.  "  At  the  post-mortem  examination  the  right  lung 
was  found  completely  collapsed,  while  the  pleural  cavity  was  full 
of  air.  A  hole,  capable  of  admitting  the  little  finger,  and  lined, 
with  lymph,  passed  through  into  the  pericardium,  forming  a  free 
communication  between  it  and  the  pleural  cavity.  The  heart  was 
uncovered  by  lung,  and  came  up  close  to  the  chest-wall ;  the  peri- 
cardium was  thickened  and  lined  throughout  with  a  thick  layer 
of  lymph,  as  was  also  the  heart,  but  there  were  no  adhesions.  It 
appeared  certain  that  a  condition  of  pneumo-pericardium  existed. 
There  was  no  sign  of  tubercle."* 


CHAPTER  XXXVIII. 

PNEUMONIA. 

Divided  in  three  Stages  as  in  Adults  :  1.  Stage  of  engorgement— Congestion  or 
splenization — 2.  Red  hepatization — 3.  Gray  or  yellow  hepatization — Pathological  con- 
dition of  the  different  stages,  similar  to  tjiose  in  adult  life.  VAmETiES  OF  Pneu- 
monia :  May  be  divided  in  children  into  three — 1.  Acute  pnei^monia  {lobar  or  croup- 
ous pneumonia)  general  and  local  signs  of  pneumonia,  the  same  disease  as  in  adidts, 
and  presents  similar  morbid  appearances — Sometimes  complicated  with  pleurisy — State 
of  the  blood  in.  Symptoms  :  General  and  physical  in  the  different  stages — Local  pain 
—  Temperature — Pungent  heat  of  skin — Cough — Dyspnoea— Abdominal  respiration — 
Pulse  and  respiration.  Causes  :  Predisposing  and  exciting — Previous  state  of  health, 
cold,  catarrh,  and  bronchitis — Eruptive  fevers — Heart  and  renal  disease.  Pathology 
of  CIeoupous  Pneumonia  :  Terminations —  Usually  in  resolution,  or  may  end.  in 
phthisis  or  chronic  pneumonia.  Prognosis  :  Doubtful  in  tubercular  cases,  or  where 
there  is  heart  or  renal  disease.  Diagnosis:  From  bronchitis — Tubercular  phthisis — 
Bronchopneumonia — Oedema  of  the  lungs — Typhoid  fever — Meningitis.  Treatiment 
of  Acute  Pneumonia  :  Venesection  not  to  be  discarded  in  some  cases — Local  bleed- 
ing by  leeches — Tartar  ated  antimony — Calomel  and  aconite — Nitrate  of  potash — Action 
of  hydrate  of  chloral  and  the  dangers  attending  its  employment — Use  of  bromide  of  po- 
tassium—Poultices  and  their  mode  of  action — Turpentine  stupes — Importance  of  stimu- 
lants if  the  child  is  feeble  or  delirious  from  exhaustion,  and  there  is  no  vascular  excite- 
ment— Treatment  of  the  second  and  third  stages — 2.  Catarrhal  pneumonia  {lobular — 
bronchopneumonia) — Relation  to  bronchitis  and  the  period  of  dentition  — Common  in 
bronchitis  and  whooping-cough — Symptoms — Pathology,  Diagnosis,  and  Treatment — 3. 
Chronic  lobular  pneumonia — Nature  and  causes — Diagnosis  from  tubercle  in  the  lung — 
Cases  in  illustration— Treatment— OEdema  of  the  lungs— Causes  and  treatment. 

Pneumonia  is  a  disease  about  which  so  much  has  been  observed 
and  written  that  it  would  be  strange  if  its  nature  and  treatment 

*  Brit.  Med.  .Tourn.,  1877,  vol.  ii,  p.  387. 


PNEUMONIA.  449 

were  not  better  understood  now  than  formerl3^  The  most  com- 
plete attention  has  been  directed  to  it,  and  the  physical  and  general 
symptoms  attending  its  various  stages  have  been  carefully  studied 
by  physicians  and  pathologists.  If  the  disease  in  consequence  of 
this  advancement  has  lessened  in  mortality  among  adults,  it  must 
still  be  viewed  as  a  serious  one  in  children.  Genuine  pneumonia 
in  early  life  is  a  formidable  and  fatal  aflection  (even  when  it  is  un- 
complicated by  renal  or  cardiac  disease) ;  the  urgent  dyspnoea,  and 
embarrassed  pulmonary  circulation,  are  soon  followed  by  coma  and 
death  if  both  lungs  are  affected,  or  even  if  one  is  rendered  nearly 
useless  as  a  breathing  organ. 

Pneumonia  in  children  is  divided  into  three  stages  of  inflamma- 
tion, as  in  adults,  and  the  same  pathological  appearances  accompany 
each  stage  of  them.  1.  The  stage  of  engorgement.  2.  The  stage 
of  red  hepatization.     '6.  The  stage  oi  gray  hepatization. 

In  the  stage  of  engorgement  the  lung  is  of  a  reddish  brick-color 
approaching  to  brown,  or  it  is  mottled  or  livid.  It  is  less  elastic, 
heavier,  and  softer,  and  this  diminution  in  its  consistence  has 
earned  the  name  of  splenization,  because  it  is  easily  torn  like  the 
spleen  itself.  Some  portions  of  the  lung  float  in  water,  and  others 
sink  from  the  small  amount  of  air  in  them,  and  when  a  section  is 
made  there  exudes  a  frothy  and  viscid  bloody  serum  containing 
air. 

In  the  stage  of  'red  hepatization  the  lung  has  lost  all  crepitation, 
and  the  weight  is  increased.  It  is  more  solid  and  distended  from 
the  amount  of  fibrinous  exudation,  and  the  marks  of  the  ribs  are 
sometimes  observed  where  the  lung  has  been  pressed  against  them. 
The  external  aspect  presents  a  deep  red  color,  and  on  section  the 
surface  is  either  marbly  or  of  a  grayish  opaque  hue.  The  granular 
appearance  is  the  characteristic  feature  of  this  stage.  Sometimes 
the  cut  surface  is  like  a  piece  of  liver.  It  is  produced  by  the 
effusion  of  coagulable  lymph  into  the  air-vesicles,  and  is  not  so 
commonly  observed  in  children  as  in  adults,  or  when  the  exudation 
IS  softer  and  thinner.  Scarcely  any  fluid  escapes  except  on  pres- 
sure, which  is  thick,  scanty,  reddish,  and  non-aerated.  The  lung 
instantly  sinks  in  water. 

In  the  third  stage,  that  of  gray  or  yellow  hepatization,  the  color 
of  the  lung  is  paler,  of  a  greenish-yellow,  or  of  a  light-gray  slate, 
and,  as  in  the  previous  stage,  it  is  dense  and  impermeable  to  air. 
The  air-vesicles  are  distended  with  inflammatory  exudation,  and 

29 


450  DISEASES    OF    CHILDREN. 

the  lung  sinks  in  water.  It  is  also  soft  and  pulpy,  and  breaks 
down  under  pressure  of  the  finger.*  On  section,  a  gray -yellowish 
fluid  (approaching  the  consistence  and  appearance  of  pus)  escapes 
in  considerable  quantity,  and  in  bad  cases  the  whole  lung  becomes 
infiltrated  with  purulent  matter,  which,  if  the  case  terminates 
successfully,  is  either  absorbed  or  expectorated.  This  stage  very 
rarely  ends  in-  abscess  and  gangrene. 

"  In  some  cases  of  pneumonic  inflammation  there  is  no  redden- 
ino;  of  the  mucous  membrane  of  the  finest  bronchial  tubes — no 
post-mortem  appearance  to  show  that  there  has  been  anything 
more  than  a  simple  uncomplicated  inflammation  of  the  air-sacs ; 
whilst  in  other  cases  an  increased  vascularity  of  the  bronchial 
membrane  indicates  the  concurrent  existence  of  bronchitic  inflam- 
mation."f 

Symptoms. — Pneumonia  in  its  first  stage  sets  in  with  rigors  and 
shivering,  high  inflammatory  fever,  pungent  heat  of  skin,  flushed 
face,  headache,  furred  tongue,  scanty  and  high-colored  urine,  pros- 
tration of  the  strength,  quick  pulse,  thirst,  loss  of  appetite,  deep- 
seated  pain  in  the  chest,  or  in  one  side  when  the  pleura  is  pri- 
marily involved,  and  a  short  dry  cough.  The  mode  of  invasion, 
however,  difiers,  as  we  shall  presently  see.  In  a  day  or  two  the 
cough  is  looser,  and  some  adhesive  mucus  is  expectorated  of  a 
rusty  or  varnish  color,  though  in  children  of  eight  or  ten  years  of 
age  there  may  not  be  the  vestige  of  expectoration.  After  this  the 
symptoms  subside,  the  expectoration,  if  any,  becomes  mucopuru- 
lent, and  in  the  course  of  ten  or  fourteen  days  the  patient  is  con- 
valescent. In  other  cases  the  symptoms  are  more  unfavorable ;  on 
the  third  or  fourth  day  the  respiration  increases  in  frequency,  and 
if  there  are  sputa  they  are  streaked  with  blood,  the  pulse  is  fre- 
quent and  feeble,  the  tongue  dry  or  brown,  and  delirium  or  coma 
comes  on,  with  the  attendant  symptoms  spoken  of  as  typhoid. 
The  last  stage  is  announced  by  fluttering  of  the  pulse,  accelerated 
respiration,  and  a  sweating  clammy  skin.  There  is  somnolence 
and  stupor,  and  the  child  is  as  heavy  and  indifl'ereut  as  though  he 

*  "The  gray  color,  indeed,  which  the  lung  presents  is  due  mainly  to  the  natural 
pigment  wliich  it  contains,  and  thus  it  happens  that  a  hepatized  lung  is  much  darker 
in  aged  persons,  where  more  natural  pigment  exists,  than  in  children,  where  pigment 
is  almost  deficient ;  tluis  it  is  that  the  hepatized  lung  of  children  is  white,  or  yellowish- 
white."     (VVilks  and  Moxon),  Pathological  Anatomy,  1875,  p.  325. 

f  Diseases  of  the  Chest,  by  Dr.  Waters,  1873,  p.  27. 


PNEUMONIA.  45 1 

was  laboring  under  a  narcotic  poison.  As  the  fatal  issue  ap- 
proaches, the  cheeks  become  pale,  and  the  lips  and  extremities  of 
the  fingers  dusky,  whilst  the  temperature  falls,  and  the  pulse  is 
gradually  extinguished.  The  local  signs  are  indicated  by  fine 
crepitation,  replacing  the  vesicular  murmur  in  the  inferior  portion 
of  the  lung,  with  dulness  on  percussion,  bronchial  breathing,  and 
increased  vocal  resonance.  There  is  puerile  respiration  in  the 
healthy  lung.  Dulness  on  percussion  and  minute  crepitation  are 
the  most  characteristic  signs.  If  the  case  pursues  a  favorable 
course,  the  bronchophony  and  bronchial  breathing  diminish,  or 
disappear,  and  large  mucous  crepitation,  or  subcrepitant  rhonchus 
takes  their  place.  If  the  inflammation  subsides,  the  crepitation  is 
gradually  succeeded  by  the  healthy  vesicular  murmur,  and  the 
lung  again  after  an  indefinite  time  becomes  resonant  on  percussion. 
When  resolution  does  not  ensue,  the  bronchophony  and  dulness 
increase,  and  vocal  fremitus  is  absent.  But  if  one  lung  becomes 
so  consolidated  that  no  air  can  enter  it,  there  is  an  absence  of 
tracheal  breathing  and  bronchophony.  If  the  hepatized  lung  sup- 
purate, and  matter  is  discharged,  amphoric  breathing  and  pecto- 
riloquy, as  in  a  phthisical  cavity,  are  to  be  expected  and  watched 
for. 

Pneumonia  does  not  follow  the  same  course  in  all  cases  ;  in  some 
delicate  and  badly-nourished  children,  one  or  more  abscesses  may 
form,  which  discharge  themselves  into  the  bronchi  or  pleura,  or 
the  fluid  parts  being  absorbed  they  undergo  calcareous  change  and 
dry  up,  surrounded  by  £i  firm  tight  membrane.  In  other  cases  the 
fibrinous  effusion  undergoes  contraction  and  shrinking,  and  leads 
to  the  condition  known  as  cirrhosis  of  the  lung,  or  "  fibroid 
phthisis."* 

We  may  now  consider  the  different  forms  and  peculiarities  of 
pneumonia  to  which  the  lung  is  liable,  and  these  are  the  following: 

Acute  pneumonia  {lobar,  or  ordinary  imeumonia — croupous  pneu- 
monia) presents  the  anatomical  ajDpearances  just  described.  It 
generally  attacks  the  lower  lobe  of  one  lung  [basic  pneumonia)  in 
adults,  but  in  children  it  may  occur  in  the  middle  lobe  also,  and 
not  unfrequently  the  apex  is  the  only  part  seized  upon,  the  rest  of 
the  lung  remaining  free.  The  apex  is  prone  to  sufl:er  in  quite 
young  children.     When  this  is  the  case  we  may  hastily  attribute 

*  See  Fibroid  Phthisis,  in  Chapter  XL,  Oa  Phthisis  Pulmonalis  or  Pulmonary 
Consumption. 


452  DISEASES    OF    CHILDREN. 

the  condition  to  tubercular  deposit,  tlaougli  this  form  of  2:)neumonia 
would  not  necessarily  seem  to  be  more  fatal  in  this  part  than  in 
the  inferior  portion  of  the  lungs.  Still  we  are  always  anxious 
when  the  apex  is  the  chosen  seat,  for  it  must  be  considered  a  sign 
of  delicate  health  or  cachexia.  More  or  less  of  bronchitis  is  usually 
present  in  these  cases,  pleurisy  is  very  common,  and  there  may  be 
some  effusion  into  the  pleural  sac.  When  pneumonia  is  at  all 
severe,  the  right  cavities  of  the  heart  are  distended,  and  the  heart 
may  be  seen  beating  at  the  epigastrium  ;  the  venous  system  is  full, 
giving  rise  to  capillary  congestion  and  enlargement  of  the  jugular 
veins.  The  blood  abounds  in  fibrin,  and  the  "bnffy"  coat  is 
present. 

Symptoms. — These  are  not  the'  same  in  all  cases.  In  some  the 
complaint  sets  in  slowly,  with  slight  bronchitis  or  catarrh  for  a 
few  days  before  the  lung  exhibits  dulness  and  the  usual  signs  of 
pneumonia.  In  other  cases  the  disease  commences  more  suddenly 
with  rigors  or  convulsions,  or  there  is  headache,  vomiting,  pain 
in  the  chest,  and  a  dry  hacking  cough.  Thirst  and  loss  of  appe- 
tite are  usually  present,  the  tongue  is  covered  with  a  creamy  fur, 
through  Avhich  the  enlarged  papilla  project,  and  there  is  constipa- 
tion. In  most  instances  there  is  pain  in  the  side,  or  about  the 
mammary  region,  extending  downwards,  which  may  lead  an  inex- 
perienced observer  to  think  the  pain  is  abdominal.  "When  the 
pain  takes  this  course  there  is  generally  some  pleurisy  present. 
It  is  piercing  or  stabbing,  causing  the  child  to  cry  out  if  the  part 
is  touched,  or  if  there  is  coughing.  The  face  is  anxious  and 
flushed,  the  nostrils  are  active  at  each  inspiration,  which  is  short 
and  catching,  and  the  little  patient  sinks  low  down  in  the  bed. 
The  skin  is  usually  acrid  and  pungently  hot,  but  it  may  be  per- 
spiring at  an  early  period  of  the  complaint,  with  no  amelioration 
to  the  other  symptoms,  the  respiration  being  equally  hurried,  and 
the  general  distress  quite  as  great.  The  temperature  varies  from 
103°  to  104°,  or  even  more,  the  latter  being  a  common  elevation 
in  children,  and  when  it  does  not  exceed  this  recovery  is  the  rule, 
but  it  should  be  borne  in  mind  that  in  cases  of  free  cutaneous 
action  it  may  never  rise  high,  and  yet  the  disease  be  extremely 
severe  and  dangerous.  The  significance  of  the  temperature  must 
be  estimated  by  comparison  of  the  physical  signs.  In  one  case 
which  came  under  my  notice,  however,  with  a  temperature  of 
105°,  the  child  had  severe  lung  mischief,  but  recovered  notwith- 


PNEUMONIA.  453 

standing.  It  is  seldom  that  the  temperature  exceeds  tins  except 
in  tubercular  pneumonia.  One  or  both  cheeks  are  often  flushed, 
or  there  is  a  livid  dusky  patch  on  them,  and  the  expression  is 
anxious  or  heav}^,  and  has  a  yellow  or  earthy  cast.  Stupor  and 
indifference  are  striking  symptoms,  as  the  complaint  steals  on, 
and  the  cough  is  choking  and  subdued,  instead  of  tearing  and 
painful. 

The  pulse  varies  in  frequency  from  120  to  140.  In  mild  cases  it 
may  not  exceed  100,  even  if  the  evening  temperature  runs  up  to 
103°,  and  the  respirations  are  not  more  than  28  to  30,  but  in 
severe  cases  the  pulse  will  reach  160,  or  even  exceed  this,  and  the 
respirations  be  as  frequent  as  70  or  80  per  minute,  particularly 
where  both  lungs  are  involved.  The  pulse  is  strong  and  full  in 
sthenic  cases  at  the  beginning,  but  as  the  disease  advances  it 
becomes  weak,  small,  and  running;  in  other  cases  it  is  irregularly 
intermittent. 

Nothing  can  usually  be  gathered  from  the  appearance  of  the 
sputa,  as  at  first  they  are  scanty,  afterwards  they  are  swallowed, 
unless  the  child  should  vomit,  when  some  rusty  or  sanguineous 
frothy  liquid  may  be  wiped  from  the  mouth,  but  the  symptoms 
are  liable  to  considerable  deviation  both  as  regards  the  local  and 
general  signs.* 

If  the  child  is  young  enough  to  be  nourished  at  the  breast,  he 
repeatedly  lets  the  nipple  fall  from  his  mouth,  because,  with  a 
closed  mouth,  the  nostrils  do  not  admit  a  sufficient  quantity  of 
air  to  the  lungs.  When  the  constitutional  symptoms  have  reached 
the  point  already  described,  the  lung  will  give  evidence  of  some 
change.  If  examined  at  the  earliest  period  the  respiration  may  be 
little  altered,  but  in  nearly  all  the  cases  I  have  seen,  when  the 
general  symptoms  have  attained  any  importance,  some  dulness 
will  be  detected  over  the  lung,  and  there  will  be  heard  on  auscul- 
tation both  rhonchus  and  sibilus.     At  the  lower  lobe  of  the  lung, 

*  Dr.  Squire  states  that  acute  (lobar,  or  croupous)  pneumonia  is  not  uncommon  irt 
childhood.  He  quotes  the  experience  of  Stenitz,  of  Breslau,  with  84  cases,  and  of' 
Ziemgsen,  of  Berlin,  who  gives  186  cases  of  pneumonia,  specifically  stated  not  to  be- 
catarrhal,  of  which  117  occurred  in  the  first  six  years  of  age,  and  69  in  the  next  ten 
years.  Four  consecutive  cases  given  by  Dr.  Squire  "  commenced  suddenly  with  higher- 
temperature  and  greater  disturbance  of  respiration  and  circulation  than  other  acute- 
diseases  of  childhood."  An  elevated  temperature  for  five  or  eight  days  suddenly  sub- 
siding marks  these  cases.  On  Infantile  Pneumonia,  read  before  the  British  Medical, 
Association  at  Manchester,  August,  1877. 


454  DISEASES    OF    CHILDREN. 

fine  crepitant  rlionclius  is  heard  at  the  end  of  inspiration,  and 
bronchial  or  tubular  breathing  above  of  a  shrill  metallic  character 
from  commencing  consolidation.  The  voice  or  cry  reaches  the 
ear  distinctly  from  the  thin  state  of  the  cliest-walls.  When  the 
sounds  just  mentioned  have  taken  place,  the  movements  of  the 
thorax  on  the  affected  side  are  restricted,  and  at  each  inspiration 
the  intercostal  muscles  are  drawn  in,  leaving  the  spaces  depressed. 
If  these  physical  signs  continue  (which  are  commonly  heard  about 
the  third  or  fourth  day),  the-  small  crepit  Ation  is  exchanged  for  a 
coarser  kind,  or  that  known  as  subcrepitant  rhonchus,  the  fluid 
now  being  more  copious  in  the  air-vesicles,  which  are  dilated  and 
enfeebled.  The  true  crepitation  of  this  form  of  pneumonia  is  very 
brief  in  children,  and  is  soon  exchanged  for  the  coarser  variety. 
As  the  disease  advances  to  recovery,  the  dulness  on  percussion 
diminishes,  and  the  crejDitation  becomes  moist  and  bubbling, 
whilst  the  respiration  is  softer  and  less  frequent.  There  is  in  this 
respect  a  great  difference  in  cases,  the  dulness  being  slow  to  pass 
away  in  some  instances,  even  if  it  does  not  become  chronic,  and 
the  breath-sounds  remaining  feeble,  harsh,  or  moist  for  a  great 
length  of  time — in  fact  a  coarse  crepitation  may  remain  after 
many  weeks,  in  defiance  of  every  constitutional  and  local  measure. 
Pneumonia  sometimes  commences  with  severe  vomiting,  and 
feverishness  ensues  at  the  end  of  two  or  three  days,  with  pain  in 
the  side,  cough,  headache,  and  restless  sleep,  followed  by  wander- 
ing, or  even  delirium  at  night ;  the  skin  is  hot  and  pungent,  and 
the  urine  high-colored,  with  deposit  of  pink  lithates  ;  it  may  con- 
tain a  little  albumen  from  congestion  of  the  kidneys,  and  there  is 
a  deficiency  of  chlorides.  Such  a  case  came  under  my  notice  in 
JSToveraber,  1876,  in  a  lad,  fourteen  years  of  age.  On  listening  to 
the  chest  the  lung  was  dull  throughout  posteriorly,  very  dimin- 
ished breath-sounds  at  base,  with  crepitant  rhonchus,  but  with 
bronchial  breathing  and  bronchophony  above,  and  in  the  lateral 
region  of  the  afl:ected  side  there  was  loose  moist  crepitation  as  high 
up  as  the  axilla.  The  patient  lay  on  his  back  (which  is  the  usual 
position  in  this  disease),  the  pulse  was  100,  fairly  soft  and  compres- 
sible, respirations  "28,  temperature  103°.  On  the  following  day 
(fourth  of  disease)  the  pulse  and  respiration  were  the  same,  but  the 
temperature  had  fallen  to  100°.  There  was  a  slight  cough,  and  ex- 
pectoration of  a  varnish  tinge.  Ten  days  later  (when  I  next  saw 
Jiim)  he  was  sitting  up,  looking  well,  except  pale.     On  examina- 


PNEUMONIA.  455 

tion  the  only  evidence  of  the  lung  attack  was  a  little  dulness  of 
the  lower  lobe,  and  deficient  breath-sounds.  The  lung  had  almost 
entirely  returned  to  its  natural  condition,  and  the  lateral  region 
presented  no  moist  sounds  whatever ;  the  pulse  was  80,  respira- 
tions 20,  temperature  normal.  The  case  was  a  mild  one,  and  came 
early  under  treatment. 

Other  cases  of  pneumonia  begin  with  delirium  in  young  sub- 
jects, and  the  83-'mptoms  are  so  obscure  that  diagnosis  is  difficult 
for  a  day  or  two  ;*  there  is  stupor,  convulsions,  or  coma,  and  the 
tongue  is  brown  with  sordes,  so  that  we  are  uncertain  whether 
the  condition  is  not  one  of  typhoid  fever.  In  adults  we  may  often 
meet  with  this,  but  in  children  it  is  not  so  -common,  and  if  the 
pyrexia  is  moderate,  and  the  bowels  quiet,  we  are  tolerably  cer- 
tain of  the  true  state  of  things.  When  the  delirium  is  fierce  and 
continuous,  and  there  is  much   headache,  the  symptoms  at  an 

*  The  nervous  symptoms  attending  apex  pneumonia  (cerebral  pneumonia)  in  young 
children  are  well  exemplified  in  the  three  following  cases.  In  the  first  case,  a  child, 
five  years  old,  was  well  on  June  12th,  and  came  home  tired  from  school.  In  the 
evening  she  was  convulsed  and  lost  her  senses ;  the  following  day  there  was  diarrhcea, 
thirst,  slight  cough,  rapid  respiration,  and  delirinm.  On  the  18th,  when  admitted 
into  the  Children's  Hospital,  under  Dr.  Gee,  the  temperature  was  105.2°  ;  pulse  160  ; 
respirations  GO ;  there  was  dulness  over  the  right  front  as  far  as  the  nipple-level,  bron- 
chial voice  and  respiration  ;  fine  rales  on  inspiration.  The  temperature  fell  on  tlie  19th 
to  100.2°,  and  on  the  20th  to  98°.  Recovered  July  5th.  In  a  second  case,  a  male  child, 
three  and  a  half  years  old,  was  in  good  health  on  July  9th  before  5  p.m.,  when  became 
indoors,  complained  of  his  head,  and  tossed  about.  In  the  evening  he  vomited.  On 
the  10th  he  was  drowsy,  and  could  not  sit  up.  On  the  13th,  wlien  admitted  into  the 
Children's  Hospital,  under  Dr.  Cheadle,  he  was  irritable  and  prostrate ;  temperature 
104.2°;  pulse  160;  respirations  52 ;  skin  hot;  tongue  red,  and  coated  with  a  white 
fur ;  right  front  of  thorax  dull  as  low  as  nipple,  and  upper  half  of  axilla ;  respi- 
ration weak  and  bronchial.  On  the  16th  he  was  screaming,  delirious,  and  constantly 
trying  to  get  out  of  bed  ;  temperature  104°.  On  the  18th  there  was  less  delirium,  but 
constant  cough.  On  the  20th  temperature  101°;  fine  crepitation  over  upper  half 
of  right  front  of  chest  to  nipple.  23d,  temperature  98.4°.  July  17th  went  home. 
In  a  third  case,  a  boy  aged  ten  years,  admitted  into  University  College  Hospital, 
under  Dr.  Ringer.  His  mother  died  of  consumption,  and  he  had  had  a  cough  tl>e 
previous  winter.  Was  suddenly  taken  ill  on  August  11th,  and  complained  of  pain  in 
head,  neck,  and  chest.  On  admission  (four  days  later)  right  front  of  chest  dull  at 
apex  ;  increased  vocal  resonance  and  fremitus ;  broncliial  respiration.  Left  back 
hyper-resonant.  Temperature  102.2° ;  pulse  133 ;  respirations  48,  to-ngue  covered  with 
a  yellow  fur,  red  at  tip  and  edges  ;  constipation.  On  the.  17th  there  was  vomiting  ; 
temperature  98.4°.  On  the  22d  there  was  scarcely  any  difference  on  tlie  two  sides 
of  the  chest.  Feels  well.  Secondary  pyrexia  followed  after  tlie  physical  signs  had 
cleared  up,  which  was  considered  due  to  the  absorption  of  inflammatory  products, 
or  allied  to  septicajmia,  as  there  were  no  signs  of  tuberculosis.  On  the  13th  of  Sep- 
tember he  was  discharged. — Cases  of  Apex  Pneumonia,  Medical  Times  and  Gazette, 
October  6th,  1877,  p.  386. 


456  DISEASES    OF    CHILDREN. 

early  period  of  the  illness  are  not  unlike  approaching  meningitis. 
In  those  eases  of  meningitis  complicated  with  pneumonia,  broncho- 
pneumonia, pericarditis,  etc.,  great  difficulties  often  present  them- 
selves in  arriving  at  a  correct  diao;nosis  till  the  characters  of  one 
or  the  other  disease  predominate. 

Causes. — These  are  predisposing  and  exciting.  Among  the 
former  are  the  previous  state  of  health,  and  the  liability  to  pul- 
monarj"  disease.  Among  the  latter  are  exposure  to  cold  in  winter 
and  spring,  particularly  after  measles  and  the  eruptive  fevers, 
debility,  privation,  violent  exercise,  congestion  from  heart  or  kidney 
disease,  or  from  tubercular  dej)Osit  in  the  lung.  The  exciting 
causes,  too,  are  exposure  to  cold  when  the  body  is  heated,  croupous 
exudation  in  the  lung,  and  the  deposit  of  diphtheria.  Injury  to 
the  chest,  or  a  blow  setting  up  abscess  in  the  walls  of  the  chest,  is 
another  ascertained  cause. 

Pathology. — The  epithelial  lining  is  unaltered  in  croupous  pneu- 
monia. The  exudation  tilling  the  alveoli  consists  of  iibrin  and 
leucocytes,  or  "exudation  cells,"  which  readily  undergo  fatty  de- 
generation; they  are  partly  thrown  off  in  the  sputa,  or  disappear 
by  absorption,  which  is  quite  different  to  what  happens  in  catar- 
rhal pneumonia.  In  the  first  aftection  the  whole  lung,  or  one 
lobe,  is  consolidated,  whilst  in  the  last-named  variety  isolated 
patches  (lobules)  are  affected,  surrounded  by  pulmonary  tissue 
permeable  to  air. 

Terminations. — Pneumonia  generally  ends  in  resolution  in 
healthy  subjects.  A  crisis  takes  place  in  the  form  of  sweating  or 
diarrhoea,  or  there  is  an  abundant  urinary  discharge,  and  forth- 
with all  the  symptoms  speedily  decline.  This  may  be  usually 
looked  for  at  the  end  of  a  week,  when  the  pulse  and  respiration 
become  reduced  in  frequency,  but  the  crisis  may  not  occur  for 
another  five  or  six  days,  leaving  the  child  prostrate,  thin,  and 
pale.  In  other  cases,  when  convalescence  appears  to  be  approach- 
ing, a  relapse  takes  place,  and  the  child  may  die  of  asphyxia  or 
convulsions  from  a  clot  of  fibrin  blocking  up  the  pulmonary  artery 
and  obstructing  the  circulation  through  the  lungs;  or  it  drags  on, 
and  at  last  perishes  from  exhaustion.  In  another  class  of  cases 
the  exudation  thrown  out  is  never  absorbed,  but  it  provokes  fever 
and  cough,  and  ultimatel}'  leads  to  phthisis  or  chronic  pneumonia, 
which  is  slowly  recovered  from  if  the  general  health  can  be  main- 
tained and  proper  treatment  is  emploj'ed. 


PNEUMONIA.  457 

Prognosis. — From  the  liability  of  young  subjects  to  tubercular 
disease,  pueumonia  is  full  of  peril  to  tbe  weak  and  delicate,  par- 
ticularly if  the  pleura  or  pericardium  has  been  involved,  or  there 
is  renal  or  heart  disease.  If  both  lungs  are  affected,  and  there  is 
copious  secretion  (especially  if  dark  or  prune-juice  in  color),  the 
respiration  increases  in  urgency,  and  collapse  is  to  be  apprehended. 
In  such  cases  profuse  perspiration  breaks  out,  low  muttering  de- 
lirium sets  in,  and  the  child  gradually  sinks. 

The  diagnosis  of  croupous  pneumonia  is  to  be  sought  in  the 
tubular  breathing,  tine  crepitation,  dulness  on  percussion,  elevated 
temperature,  and  rapid  respiration.  Change  from  the  normal  ratio 
between  frequenc}^  of  pulse  and  frequency  of  respiration  is  very 
marked  is  this  disorder.  In  any  febrile  disturbance  in  young 
children  the  temperature  is  apt  to  run  rapidly  high,  even  in  den- 
tition, but  then  it  is  of  very  brief  duration  compared  to  pneumo- 
.nia,  and  in  bronchitis  it  is  not  usually  so  high,  though  I  have 
known  it  reach  105°  when  the  disease  has  been  limited  to  the 
bronchi  alone,  and  the  pulmonary  tissue  has  escaped.  The  rhonchi 
of  pneumonia  are  more  sonorous  and  scanty,  and  the  moist  crepi- 
tation is  not  so  loose  and  bubbling  as  in  bronchitis.  When  acute 
lobar  pneumonia  attacks  the  upper  lobe  of  a  lung,  it  is  liable  to 
be  mistaken  for  phthisis.  The  exudation  poured  out  in  these 
cases,  and  the  dulness  and  tubular  breathing,  are  just  the  signs 
which  ensue  from  tubercular  deposit.  The  local  indications  are 
often  trifling,  however,  compared  to  the  febrile  disturbance  and 
prostration,  and  time  alone  may  be  capable  of  clearing  up  the 
diagnosis.  In  the  case  of  simple  inflammation  the  local  and  gen- 
eral symptoms  soon  pass  off,  whilst  in  tubercular  cases  they  gradu- 
ally become  worse,  or  merge  into  the  chronic  form,  when  the  diag- 
nosis is  all  the  more  difficult,  if  not  impossible.  Physical  signs 
cannot  clear  up  the  difficulty,  for  both  in  pneumonia  and  apex 
consolidation  from  tubercle  there  is  great  dulness,  bronchophony, 
and  bronchial  respiration,  to  indicate  that  the  lung-tissue  at  this 
part  is  consolidated.  Miliary  tubercle  may  give  rise  to  no  signs 
whatever,  and  the  disease  usually  creeps  on  but  slowly,  with  fever 
and  emaciation,  cough,  and  loss  of  appetite.  Tubercle  may  be 
present  in  some  other  parts  of  the  bod}^,  and  there  may  be  a  his- 
tory of  it  in  the  family.  The  diagnosis  from  pleurisy  is  given  in 
the  chapter  devoted  to  that  subject. 

The  symptoms  of  lobar  'pneumonia  differ  from  those  of  lobular 


458  DISEASES   OF   CHILDREN. 

or  catarrhal  imeuinonia  in  the  greater  dyspnoea  of  the  latter  affec- 
tion, the  duskiness  of  the  lips,  and  the  pallid  and  hloated  counte- 
nance. There  is  more  restlessness  and  anxiety,  the  cough  is  loose 
and  choking,  and  mucopurulent  phlegm  is  often  dislodged  frora 
the  air-passages  by  a  paroxysm  of  suffocative  cough  or  vomiting. 
AVhen  the  child  is  too  young  or  feeble  to  expectorate,  the  sounds 
over  the  affected  tubes  are  loose  and  extensive.  The  symptoms 
in  this  variety  come  on  earlier,  and  the  vital  prostration  is  more 
marked. 

Pneumonia  may  be  distinguished  from  oedema  of  the  lungs  by 
the  dulness  on  percussion  and  the  tubular  breathing,  whilst  in  the 
latter  affection  the  sputa  are  frothy  and  thin,  and  the  complaint 
occurs  as  the  consequence  of  long-continued  congestion  from  heart 
or  kidney  disease.  The  onset  of  pneumonia  may  be  mistaken  for 
typhoid  fever,  and  even  meningitis,  but  these  have  been  alluded 
to  in  another  place.* 

Ireatment  of  Lobar  Pneumonia. — In  the  acute  congestive  stage, 
if  the  child  is  strong  enough,  and  there  is  much  pain  in  the  side, 
the  application  of  a  few  leeches,  or  even  venesection,  is  not  to  be 
neglected.  But  it  is  of  the  greatest  importance  to  be  verj^  cautious 
in  the  selection  of  cases  for  this  heroic  treatment ;  these  will 
almost  invariably  be  found  in  country  practice,  and  seldom  in  large 
towns  and  cities.  Ko  doubt  children  have  been  so  saved  when  all 
other  remedies  have  failed,f  and  the  plan  is  always  one  to  be  held 

*  See  Chap.  VIII,  On  Tvplioid  Fevei-,  and  Chap.  XLII,  On  Diseases  of  tlie 
Brain. 

t  "  In  a  heahhy  child  of  four  years  old  a  vein  may  be  opened  in  the  arm,  and  four 
ounces  of  blood  may  be  allowed  to  flow,  provided  that  faintness  be  not  earlier  produced, 
without  tliere  being  any  reason  for  us  to  apprehend  that  tlie  plan  we  are  adopting  is 
too  energetic.  It  often  liappens  that  the  child  faints  before  this  quantity  of  blood  has 
been  drawn,  while  in  other  cases  not  above  one  or  two  ounces  can  be  obtained  ;  still, 
whenever  the  patient  is  seen  at  the  commencement  of  the  attack,  general  depletion  is 
desirable,  even  though  it  should  be  necessary  to  follow  it  up  by  local  bleeding ;  for  the 
immediate  effect  which  it  produces  is  greater  than  that  which  follows  depletion,  and 
the  quantity  of  blood  abstracted  by  it  is  definite ;  while,  if  both  the  nurse  and  the  med- 
ical attendant  understand  how  to  manage  children,  it  may  be  conducted  so  as  to  cause 
them  but  little  excitement  or  alarm.  If  but  very  little  blood  can  be  drawn  frora  the 
arm,  or  if,  as  is  not  seldom  the  case  with  infants  under  two  years  of  age,  it  be  not 
possible  to  find  a  vein,  depletion  nuist  be  accomplished  by  means  of  leeches,  which,  for 
reasons  already  stated,  it  is  desirable  to  ajjply  beneath  the  scapula.  How  great  soever 
may  have  been  the  relief  which  followed  the  first  bleeding,  it  is  not  always  permanent, 
and  hence  tlie  child  sjiould  Ije  seen  again  in  from  six  to  eight  hours;  and  if  the  symp- 
toms ajjpear  to  be  returning  with  any  tiling  of  tlie  former  severity,  depletion  must  be 


PNEUMONIA.  459 

in  mind,  as  it  frequently  saves  the  lung  from  organic  change  and 
preserves  life.  Every  case,  however,  must  be  treated  on  its  own 
merits,  and  if  suitable  diet  and  rest  are  observed  the  patient  may 
be  left  to  nature  in  many  cases.  Two  or  three  leeches  to  the  side 
in  sthenic  cases  have  relieved  pain  and  rapid  breathing,  causing 
the  blood  to  circulate  more  freely  through  tlie  lungs,  controlling 
the  temperature,  and  lessening  the  violence  of  the  heart's  action. 
This  treatment  should  be  resorted  to  early  in  the  disease. 

Tartarated  antimony  is  a  most  useful  drug,  and  in  strong  children 
it  may  be  given  advantageously  for  a  short  time  in  small  doses,  as 
gr.  ,'.^th  to  ^th,  with  the  solution  of  acetate  of  ammonia,  or  the 
dilute  hydrocyanic  acid  (Form.  60).  The  antimony  acts  best  when 
it  does  not  provoke  vomiting,  but  simply  determines  to  the  skin 
and  lowers  vascular  action.  Valuable  as  antimon}^  undoubtedly 
is,  it  must  be  used  with  great  caution,  and  watched  very  care- 
fully, for  in  young  children  it  soon  causes  depression  and  faintness, 
and  if  the  occurrence  of  these  symptoms  is  not  guarded  against, 
the  local  signs  increase  instead  of  improving.  This  again,  like 
bleeding,  is  only  suitable  for  strong  children  in  the  early  stage  of 
the  disease,  and  not  for  those  w^ho  have  been  reared  in  the  con- 
taminated atmosphere  of  large  towns.  A  few  drops  of  antimonial 
wine,  with  citrate  of  potash  and  the  solution  of  acetate  of  ammo- 
nia or  spirit  of  nitrous  ether,  wnll  keep  up  a  gentle  action  of  the 
skin  and  brino;  relief.  Emetics  are  not  indicated  in  this  form  of 
pneumonia. 

With  the  tendency  to  exudation  of  lymph  mercury  ma}''  be 
employed,  but  more  sparingly  in  this  than  in  some  other  paren- 
chymatous inflammations.  When  the  constitution  will  bear  it,  its 
action  as  an  antiphlogistic  may  shorten  the  stage  of  exudation, 
and  promote  and  hasten  the  absorption  of  the  newly  effused  lymph 

repeated,  though  then  local  bloodletting  is  to  be  preferred  to  venesection,  even  in  cases 
in  which  bleeding  from  the  arm  had  been  resorted  to  in  the  first  instance.  It  must 
never  be  forgotten  that  in  the  child,  as  well  as  in  the  adult,  no  subsequent  care  can 
make  up  for  the  inefficient  treatment  of  the  early  stage  of  pneumonia ;  if  the  first 
twenty-four  hours  be  allowed  to  pass  while  you  are  employing  inadequate  remedies,  the 
lung,  which  at  first  was  merely  congested,  will  have  become  solid,  and  recovery,  if  it 
takes  place  eventually,  will  be  tardy,  and  perhaps  imperfect.  On  the  other  hand, 
cases  that  set  in  with  the  greatest  severity  sometimes  appear  to  be  at  once  cut  short  by 
free  depletion ;  the  violent  symptoms  being  arrested,  and  recovery  going  on  uninter- 
rn[)tedly,  almost  without  the  euiployment  of  any  other  remedy." — West,  Diseases  of  In- 
fancy  and  Childhood,  1859,  4th  edition,  p.  321. 


460  DISEASES    OF    CHILDREN. 

before  it  has  had  time  to  become  organized,  and  to  act  as  an  irri- 
tant to  the  surrounding  healthy  textures.  Small  doses  of  calomel 
with  a  few  grains  of  James's  powder  maj  be  sometimes  given  with 
advantage  (Form.  62).  Minim  doses  of  tincture  of  aconite  are 
also  useful  from  their  power  in  promoting  diaphoresis.  The  anti- 
phlogistic effects  of  aconite  are  very  marked  in  relieving  tension 
in  the  pulse,  and  lowering  arterial  pressure,  but  this  drug  tends  to 
reduce  the  respiratory  movements  as  well  as  the  temperature,  and 
acts  as  a  sedative  on  the  cardiac  circulation.  I  have  never  ob- 
served any  bad  effects  follow  its  administration  in  acute  pyrexia 
in  small  and  repeated  doses,  but  great  benefit  where  the  vascular 
excitement  has  been  considerable,  and  the  skin  pungently  hot.* 

When  the  physical  signs  announce  that  the  lung  is  freely  secret- 
ing, and  sthenic  action  is  reduced,  a  grain  or  two  of  the  carbo- 
nate of  ammonia  may  be  given,  particularly  if  the  pulse  is  weak 
or  unsteady,  and  there  are  signs  of  collapse,  when  it  may  be  safely 
combined  with  decoction  of  oak  bark,  or  senega.  Whilst  the 
sputa  are  viscid  and  the  urine  turbid,  alkalies  are  indispensable. 

A  few  grains  of  hj^drate  of  chloral  may  be  of  service  where  de- 
pression is  to  be  apprehended  from  the  want  of  sleep.  We  should 
bear  in  mind  that  it  lessens  the  activity  of  the  respiratory  centre 
and  enfeebles  the  vasomotor  system — a  state  of  things  we  are 
most  anxious  to  guard  against.  Its  action  is  also  very  manifest 
on  the  circulation,  lowering  and  weakening  the  action  of  the  heart, 
by  paralyzing  its  sympathetic  ganglia.  The  combination  of  bella- 
donna tends  to  obviate  this.  I  should  never  administer  it  where 
the  pulmonary  circulation  was  much  involved,  for  fear  of  increas- 
ing relaxation  in  the  vessels  and  further  enfeebling  the  action  of 
the  heart. f 

Bromide  of  potassium  is  a  safer  remedy,  having  a  sedative  in- 
fluence on  the  nervous  system,  and  so  inducing  sleep,  without  de- 
pressing the  heart's  action. 

In  the  shape  of  local  applications,  nothing  equals  a  warm  linseed 
or  jacket  poultice.  It  should  be  applied  over  the  whole  of  the 
affected  lung,  as  hot  as  can  be  borne,  and  changed  once  in  two  or 

*  See  the  action  of  Aconite  in  Chap.  XI,  On  Scarlet  Fever. 

f  "  The  breathing  tends  to  become  shiwer,  and  finally  to  cease,  from  paralysis  of 
the  respiratory  centre ;  but  urgent  dyspnciea  has  occasionally  been  observed,  and  this 
has  been  ascribed  to  dilatation  of  the  pulmonary  vessels,-  causing  an  increased  afflux 
of  blood  to  be  directed  suddenly  to  the  lungs." — Guide  to  Therapeutics,  by  Dr.  Farqu- 
harson,  1877,  p.  132. 


PNEUMONIA.  461 

three  hours.  The  fault  of  poultices  in  general  is  that  they  are  not 
made  large  enough  to  envelop  the  diseased  organ,  for  the  object 
aimed  at  is,  not  only  to  relieve  pain  but  to  draw  the  blood  to  the 
surface,  and  so  to  act  as  a  sedative  on  the  inflamed  or  congested 
parts  beneath.  "In  lung  diseases  of  children,  whose  chest-walls 
are  very  thin,  the  value  of  poultices  has  seemed  to  be  much  greater 
than  in  corresponding  affections  in  adults  ;  and  it  is  not  illogical 
to  believe  that  the  difl^erence  may  be  dependent  upon  the  irregu- 
larity of  the  chest-walls."*  When  moderately  and  cautiously  used 
a  turpentine  stupe  is  very  serviceable.  A  piece  of  thick  household 
flannel  should  be  folded  the  required  size,  then  wrung  out  of  hot 
water,  and  a  few  drops  of  turpentine  sprinkled  over  it.  This 
should  be  laid  over  the  affected  part  of  the  lung,  and  covered  with 
a  piece  of  oiled  silk,  or  a  dry  fold  of  linen  rag,  and  kept  on  for 
twenty  minutes.  When  it  is  removed  the  skin  will  be  found  of  a 
bright  erythematous  hue,  and  the  cutaneous  vessels  will  be  kept 
dilated  for  a  considerable  time. 

The  diet  should  be  light,  and  at  first  without  stimulants.  After 
about  five  days  or  a  week,  when  the  temperature  falls  (perhaps 
with  crisis  of  diarrhoea  or  sweating),  wine,  eggs,  and  additional 
nourishment  are  needed.  In  all  cases,  milk,  beef  tea,  and  cooling 
drinks  from  the  onset,  should  be  given  freely.  The  temperature 
of  the  room  should  be  about  60°  and  well  ventilated  ;  the  head 
raised,  and  the  position  changed  frequently. 

In  the  treatment  of  the  second  stage,  or  that  of  hepatization,  a 
flying  blister,  or  the  application  of  iodine  may  be  needed,  but 
this  will  be  more  fully  alluded  to  when  we  come  to  speak  of  the 
disease  in  its  chronic  form.  The  perchloride  of  mercury  in  small 
doses,  iodide  of  potassium,  and  cinchona,  are  valuable  remedies  in 
their  turn.  The  ammonio-citrate  of  iron,  or  the  syrup  of  the 
iodide,  are  both  useful  remedies,  particularly  if  the  child  is 
antemic. 

In  the  third  stage,  carbonate  of  ammonia,  brandy,  quinine,  and 
the  mineral  acids  may  be  required,  followed  by  cod-liver  oil  and 
change  of  air. 

2.  Catarrhal  Pneumonia  [acute  lobular  j^neumonia^einthelial  j)neu- 
wonia),  Bronchoimeumoma. — In  this  variety  distinct  and  separate 
lobules  are  affected.  The  inflammation  extends  along  the  smaller 
bronchial  tubes  to  the  air-vesicles,  or  it  originates  in  collapsed 

*  Wood  on  Therapeutics,  1876,  p.  558. 


462  DISEASES  or  childeen. 

lobules,  which  are  firm  and  red.  On  section  they  are  smooth  and 
give  exit  to  a  bloody  fluid.  It  is  very  common  in  whooping-cough, 
measles,  and  diphtheria,  but  it  may  arise  apart  from  these  diseases 
in  consequence  of  debility  and  an  impure  atmosphere.  Cold  and 
changes  of  weather  appear  to  be  the  most  common  causes,  and  any 
exhausting  disease  which  has  kept  the  child  for  a  long  time  in  the 
recumbent  posture  is  capable  of  originating  this  mixed  disorder. 
Children  who  are  delicate  from  birth  and  have  bronchitis  are  sub- 
ject to  it.  I  have  met  with  children  of  fifteen  months  old  with 
symj)toms  of  wasting  and  marasmus  who  get  bronchitis.  The 
wheezing  extends  down  the  bronchi,  and  involves  the  smaller  bron- 
chial tubes  of  one  lung,  increasing  the  frequency  and  urgency  of 
the  respiration,  and  by  retarding  the  circulation  through  the  lower 
portion  of  the  lung  leads  to  dulness  and  consolidation  of  it.  The 
lips  become  blue,  and  the  skin  breaks  out  into  a  cold  clammy 
perspiration.  The  temperature  may  reach  104°  or  105°,  but  it  is 
not  maintained  at  this  height,  the  pulse  200,  small,  thrilling,  and 
collapsing,  and  the  respirations  60  or  even  100  per  minute.  The 
child  is  extremely  restless,  turning  about  and  hiding  the  ball  of 
the  eye  beneath  the  upper  eyelid.  The  dulness  may  creep  up- 
wards above  the  spine  of  the  scapula,  and  tubular  breathing  be 
detected  below  the  clavicle  on  the  same  side.  There  is  phlegm, 
which  cannot  be  dislodged,  and  the  child  cries  out  when  he  coughs, 
and  only  gets  snatches  of  sleep.  Soon  the  lung  is  dull  throughout, 
and  the  alse  nasi  are  active ;  large  and  loose  crepitation  succeed, 
the  respiration  becomes  rattling,  and  the  child  may  die  in  a  con- 
vulsion, or  pass  into  coma  and  sink.  In  other  cases  the  crepitation 
which  has  been  heard  during  the  pure  bronchitic  stage  is  succeeded 
in  a  day  or  two  by  tubular  breathing,  harsh  and  dry;  .the  dulness 
increases,  and  becomes  apparent  in  front  as  well  as  behind. 

Lobular  pneumonia,  when  it  is  at  all  severe,  is  a  frequent  out- 
come of  bronchitis,  indeed  the  two  conditions  constantly  occur 
too-ether,  but  they  must  be  recognized  as  separate  and  distinct 
diseases,  having  a  different  clinical  and  pathological  importance. 
"  Lobular  pneumonia  is  always  a  secondary  disease,  either  to  those 
specific  disorders  which  are  accompanied  by  bronchitis  almost  as 
one  of  their  elements  (in  which  rank  measles  and  whooping-cough 
stand  obviously  first),  or  to  bronchitis  of  a  primary  kind.  So  far 
as  careful  post-mortem  observation  permits  a  generalization  to  be 
made,  the  course  of  the  disease  is  invariably  through  the  occurrence 


PNEUMONIA.  4G3 

of  collapse.  After  a  lobule  has  become  emptied  of  air,  and  after 
more  or  less  of  the  bronchial  contents  have  been  forced  by  inspira- 
tory action  into  the  alveoli,  the  lobule  itself  passes  into  a  state  of 
active  congestion,  and  then  of  hepatization,  and  by  degrees  the 
test  of  inflation  gives  only  a  partial  result,  and  eventually  no  air 
can  be  forced  into  the  lobule.  The  microscope  shows  in  the  earlier 
periods  of  this  consolidation  the  parenchyma  of  the  lung  unchanged, 
but  the  alveoli  stufied  with  cells  and  their  epithelium  occasionally 
undergoing  some  fatty  change.  The  next  anatomical  change  is 
the  coalescence  of  these  collapsed  and  inflamed  lobules  into  larger 
masses,  which  frequently  give  rise  to  consolidation  of  large  por- 
tions of  the  lung,  especially  of  the  posterior  surface.  In  these, 
next,  a  softening  change  goes  on,  and  the  centre  of  the  lobule 
loses  the  dull-brown  color  of  the  rest,  and  becomes  gray  and  dif- 
fluent, the  liquid  part  having  all  the  characters  of  pus.  Or  another 
process  may  be  set  up  in  the  occluded  lobule,  and  a  cheesy  matter 
be  formed,  which  to  the  microscope  presents  various  fatty  elements 
and  nuclei.  This  occurs  at  a  later  stage  of  the  disease  in  unhealthy 
children,  in  whom,  however,  miliary  tubercle  need  not  exist.'"* 

Pathology. — Unlike  the  croupous  form  of  pneumonia  we  have 
just  considered  there  is  no  fibrinous  exudation,  but  a  cell  pro- 
liferation which  distends  the  alveoli  at  the  termination  of  the 
smallest  bronchi.  These  cells  are  derived  from  the  epithelial 
lining  of  the  alveoli  where  they  remain,  and  as  they  cannot  be 
readily  discharged  by  expectoration,  they  accumulate,  cause  local 
irritation,  and  form  into  masses,  which  undergo  retrogressive 
changes.  Hence  the  inflammation  may  lead  to  abscesses  in  the 
lungs  or  to  caseous  degeneration  [scrofulous  pneumonia)^  or  to 
tuberculosis,  and  that  terrible  acute  form  of  phthisis  known  as 
'■'■  galloping  consumption."  In  some  protracted  cases  the  disease 
may  terminate  in  chronic  pneumonia. 

Treatment. — In  this  variety  lowering  measures  must  be  dis- 
carded. Ipecacuanha  wine  in  a  saline  mixture,  and  carbonate  of 
ammonia,  senega,  and  tolu,  are  the  remedies  to  be  depended  upon 
(Form.  61,  65,  ^Q).  When  there  is  an  accumulation  of  phlegm  in 
the  air-tubes  an  emetic  at  night  to  dislodge  it  will  relieve  the 
breathing  and  insure  rest.  Some  of  the  best  effects  have  followed 
the  use  of  mild  emetics  at  bedtime  in  these  and  other  similar 

*  Lettsomian  Lectures — On  the  Diagnosis  and  Management  of  Lung  Diseases  in 
Children,  by  George  Buchanan,  M.D.,  F.R.C.P.,  The  Lancet,  Feb.  8th,  1868,  p.  215. 


464  DISEASES   OF   CHTI.DREN. 

cases,  as  broncliitis  or  whooping-cough,  where  the  bronchial  tubes 
are  loaded  with  mucus.  I  have  not  observed  any  bad  effects 
follow  the  use  of  a  teaspoonful  of  ipecacuanha  wine,  followed  by 
a  little  warm  water,  till  vomiting  ensues,  unless  the  child  is  very- 
exhausted.  Generally  one  or  two  doses  will  be  enough,  but  if  the 
child  is  prostrate,  and  there  is  lividity  of  the  face  and  mucous 
membranes,  with  a  feeble  pulse  and  shallow  respiration,  the 
ipecacuanha  failing  to  excite  cough  or  vomiting  will  increase  the 
general  distress.  The  bronchial  tubes  remain  loaded  with  phlegm 
and  mucus,  and  the  general  discomfort  and  pain  in  the  chest 
cannot  be  relieved  so  long  as  the  mucus  remains.  In  these  cases 
it  may  be  well  to  combine  the  ipecacuanha  with  a  stimulant  like 
the  carbonate  of  ammonia,  or  a  few  grains  of  sulphate  of  zinc, 
and  if  its  action  is  delayed,  to  tickle  the  fauces  with  a  feather, 
but  even  these  attempts  sometimes  fail,  and  then  our  only  chance 
is  to  place  the  child  in  as  upright  a  position  as  possible  in  bed 
and  support  the  failing  circulation  by  ammonia,  spirit  of  chloro- 
form, wine,  and  beef  tea.  When  an  emetic  acts  efficiently  it 
excites  the  action  of  the  respiratory  muscles,  empties  -the  larger 
tubes  of  their  tough  or  fluid  contents,  and  stimulates  the  smaller, 
bronchi  to  renewed  secretion  and  activity.  The  dry  sounds  and 
hyper£emia  of  the  mucous  membrane  diminish  and  give  place  to 
moist  crepitation,  and  resonance  on  percussion.  The  expression 
changes  and  becomes  lively  and  animated,  the  duskiness  of  surface 
passing  off  as  the  blood  is  better  aerated,  and  the  child  is  restored 
by  refreshing  sleep. 

The  carbonate  of  ammonia  is  an  excellent  remedy  by  loosening 
the  contents  of  the  bronchi,  and  favoring  expectoration,  I  have 
many  times  known  children  expectorate  or  bring  up  phlegm  by 
coughing,  just  in  proportion  as  they  have  taken  the  remedy  or 
not.  When  the  temperature  is  high  and  the  pulse  weak  and  quick, 
I  have  seen  excellent  efiects  from  combining  the  ammonia  with 
quinine  and  senega.*  This  encourages  expectoration  and  improves 
the  pulse  and  appetite.     If  the  tongue  is  furred,  and  the  sputa 

*  Formula  69 : 

R.    Aram,  curb., gr.  viij 

Tinct.  qiiinia', .         .  S'n'] 

Spt.  cliloroform, "Kxx 

wSyr.  to] lit., .^iij 

Decoct,  senegfc  ad ^iv. — M. 

A  table.spoonful  every  four  hours.     For  children  five  or  six  years  old. 


PNEUMONIA.  465 

thick  and  tenacious,  the  ammonia  may  be  given  with  bicarbonate 
of  potash  and  ipecacuanha.'^  When  there  is  no  tendency  to  ac- 
cumulation in  the  bronchi,  and  the  cough  is  irritating  and  the 
child  restless,  a  few  drops  of  the  compound  tincture  of  camphor, 
or  henbane,  may  be  safely  added. 

As  to  diet,  the  child  should  be  fed  with  milk  and  lime-water, 
chicken  or  veal  broth,  and  a  few  drops  of  brand v  may  be  added  to 
the  milk  three  or  four  times  a  day.  In  feeble  children  of  only  a 
year  old  I  have  sometimes  given  a  little  champagne  in  potash- 
water,  with  excellent  results,  and  I  consider  that  recovery  is  often 
due  to  the  rallying  effect  of  the  wine. 

As  regards  local  applications,  warm  linseed  poultices,  with  or 
without  mustard,  as  we  have  mentioned  under  lobar  pneumonia, 
will  be  of  most  benefit. 

Later  on,  the  preparations  of  iron — the  syrup  of  the  iodide,  the 
syrup  of  the  phosphate  (syrup,  ferri  phosp.,  B.  P.),  the  chemical 
food  (syrup,  ferri  phosp.  comp.),  or  the  vinum  ferri,  will  be  neces- 
sary to  strengthen  the  system  and  improve  the  quality  of  the  blood. 
During  convalescence  cod-liver  oil  or  Squire's  malt  extract  will  be 
found  serviceable,  or  they  may  be  combined  with  great  advantage. 
The  latter  remedy  may  be  given  in  milk. 

3.  Chronic  Lobular  Pneumonia. — This  is  a  disease  of  great  in- 
terest and  importance  from  its  liability  to  be  mistaken  for  tuber- 
culosis or  chronic  phthisis.  The  connective  tissue  between  the 
lobules  is  atfected,  leading  to  induration  and  consolidation  of  the 
pulmonary  tissue.  It  generally  follows  bronchitis,  pneumonia, 
measles,  or  diphtheria,  or,  what  is  far  more  common,  it  creeps  on 
insidiously  in  bad  states  of  health,  and  may  prove  persistent  and 
troublesome.  I  have  met  with  it  in  feeble  children  of  rickety  con- 
stitution, and  for  weeks  together  could  not  decide  whether  the 
disease  was  tubercular  or  not.  In  fact,  until  a  case  of  this  form 
of  pneumonia  had  been  for  some  time  under  observation,  it  is  im- 
possible to  come  to  a  decision.    When  we  are  sure  that  a  child  has 

*  Formula  70 : 

R.    Amm.  carb.,  .         .        .         .         .         .         .         .  gr.  vii 

Potass,  bicarb.,     .         .         .         .         .         .         .         •  9ij 

Vin.  ipecac, njjxl 

Syr.  tolut., giij 

Aquam  ad Jiv. — M. 

A  tablespoonful  every  four  hours.     For  children  five  or  six  years  old. 

30 


466  DISEASES    OF    CHILDEEX. 

enjoj'ed  good  health  till  an  attack  of  bronchitis  or  whooping- 
cough  has  happened,  and  then  the  complaint  passes  into  localized 
dulness  below  one  clavicle  or  scapula,  with  or  without  moist  crepi- 
tation and  bronchophony,  we  are  generally  correct  in  assuming 
that  the  complaint  is  of  simple  origin.  The  two  following  cases 
exemplify  this  condition. 

Chronic  lobular  pneumonia,  simulating  tuberculosis ;  recovery. 

Case  1. — V.  B ,  set.  9|,  was  admitted  into  the  Samaritan 

Hospital,  under  my  care,  on  March  25th,  1875.  He  was  a  pale, 
thin,  emaciated  boy,  with  light  hair  and  gray  eyes,  and  had  been 
ailing  in  health,  more  or  less,  for  five  years.  There  was  no  history 
of  an  acute  attack.  Had  had  both  whooping-cough  and  measles; 
his  mother  dated  his  delicacy  to  an  attack  of  quinsy  three  years 
previously. 

On  examination  there  was  a  general  flattening  of  the  thorax 
below  the  clavicle,  especially  on  the  left  side,  to  the  inner  aspect 
of  the  corresponding  nipple,  and  this  was  in  a  great  measure  due 
to  imperfect  development  of  the  left  half  of  the  thorax.  He  could 
take  a  full  inspiration,  at  the  termination  of  which  was  a  cooing, 
dry,  bronchial  sound,  not  heard  on  the  right  side.  The  percussion- 
note  was  good  in  front,  but  nowhere  clear  behind  ;  the  respiration 
was  harsh  and  irregular,  and  there  was  distinct  bronchophony,  but 
no  moist  sound  ;  the  pulse  was  variable,  the  least  fatigue  or  ex- 
citement at  once  accelerating  it,  and  I  have  felt  it  one  day  as  low 
as  72,  and  another  as  high  as  112 ;  the  respirations  were  tranquil, 
and  did  not  exceed  20  per  minute,  the  morning  and  evening  tem- 
perature 99.2°.  He  was  ordered  a  diet  of  milk,  eggs,  and  beef  tea  ; 
a  mixture  of  hydrochloric  acid  and  quinine ;  diluted  tincture  of 
iodine  (one  in  seven)  to  be  painted  under  the  left  collar-bone  night 
and  morning. 

'  In  May  he  was  much  better,  and  in  June  he  had  gained  in  flesh 
and  weight,  and  his  general  health  was  most  satisfactory.  Tem- 
perature normal ;  pulse  72,  respirations  20.  The  pliysical  signs 
still  indicated  some  remaining  dulness  and  bronchophony  between 
the  scapulse.     He  was  discharged  well  on  June  23d. 

Readmitted  February  17th,  1876. — Some  time  after  leaving  the 
hospital  he  seemed  to  be  in  perfect  health,  but  latterly  he  had 
lost  much  flesh  and  strength.  The  wasting  was  most  apparent 
about  the  temples,  in  the  arras  and  legs,  and  in  the  shrunken 
hands,  the  sternum  and  scapular  region.     He  looked  like  a  child 


PNEUMONIA.  467 

in  the  last  stage  of  plitliisis.  The  chest  was  clear  on  percus- 
sion, and  expansion  was  everywhere  good,  the  inspiration  was 
rather  short  and  harsh,  but  there  was  no  dnlness,  and  the  vocal 
vibration  was  slight.  As  the  expiratory  note  was  not  caught  at 
all,  its  suppression  was  probably  due  to  nervousness.  In  the 
right  supra-scapular  space,  inspiration  was  short  and  rather  harsh, 
but  there  was  neither  dulness  nor  vocal  vibration.  Immediately 
below  the  spine  of  the  scapula,  and  over  the  centre  of  the  bone, 
small  crejDitant  rhonchus  was  most  distinct,  which  disappeared 
between  the  inner  border  of  the  scapula  and  the  spine;  over  the 
middle  lobe  of  the  lung  there  were  coarse,  loose,  and  moist  bubbling 
rhonchi  (suspected  softening  of  middle  lobe\  and  dulness  was 
very  marked  from  this  point  downwards.  There  was  no  bron- 
chophony, the  complete  absence  of  which  I  could  not  explain,  but 
on  inspiration  the  air  seemed  to  be  entering  some  small  cavity,  the 
thin  sternal  walls  only  intervening  between  it  and  the  ear,  when 
applied  to  the  chest-wall.  There  was  some  consolidation  of  the 
lung.  In  the  middle  and  lower  lobes  of  the  right  side  there  was 
heard  crepitant  rhonchus,  precisely  resembling  the  small  crepi- 
tant rlionchus  of  pneumonia;  over  this  the  percussion-note  was 
resonant.  The  urine  was  turbid,  slightly  alkaline,  and  rather  high- 
colored,  with  a  sp.  gr.  1024  ;  on  boiling,  flakes  like  albumen  floated 
freely  in  the  specimen,  which  immediately  disappeared  with  effer- 
vescence (phosphates)  on  the  addition  of  nitric  acid.  The  pulse  was 
96,  and  of  good  calibre ;  the  respirations  20 ;  the  morning  tem- 
perature was  99.4°,  the  evening  100°.  The  variation  in  breathing 
was  very  noticeable  here — one  minute  only  breathing  twenty  times, 
and  another  as  many  as  twelve  times  in  the  quarter  of  a  minute, 
just  as  we  see  in  some  cases  of  tubercular  meningitis,  and  gradual 
death  from  exhaustion.*  He  was  never  fl.ushed,and  there  was  no 
sweating.  He  was  ordered  quinine,  phosphoric  acid,  and  cod- 
liver  oil. 

22d. — The  urine  was  unchanged — he  was  ordered  port  wine. 

24th. — There  was  more  loose  crackling  in  the  lung,  which  ap- 
peared to  be  breaking  down,  as  gurgling  and  pectoriloquy  were 
distinct,  and  when  he  whispered  the  sound  travelled  up  the  stetho- 
scope distinctly. 

March  9th. — During  the  last  few  days  no  bronchophony  or 
gurgling  was  to  be  heard. 

*  See  Chap.  XLII,  On  Diseases  of  the  Brain. 


468  DISEASES    OF   CHILDREN. 

24tli.— ^Ile  had  gaiuecl  flesh  and  looked  better,  and  although  his 
appetite  was  good  his  cough  was  still  troublesome.  The  change  in 
the  physical  signs  of  the  lung  was  very  remarkable  ;  the  note  was 
clear  throughout  the  surface  of  the  right  lung,  there  was  no 
trace  of  bronchophony  or  moist  sound  of  any  kind,  except  a  little 
dry  crackle  ;  all  the  characteristic  signs  of  breaking-down  of  lung- 
texture  on  the  24th  ult.  had  disappeared.  The  only  sound  now  was 
prolonged  expiration  and  diminished  expansion  on  this  side.  It 
is  possible  that  the  cause  of  this  was  due  to  some  ^'- lobular  "pneu- 
monia^' of  a  chronic  character  pressing  on  the  tubes,  and  that  con- 
solidation of  lung-tissue  was  set  up. 

April  21st. — The  only  change  now  detectable  was  that  the  respi- 
ratory murmur  was  weaker  over  the  affected  side  than  the  left, 
every  trace  of  crackling  and  consolidation  having  disappeared.  lie 
was  ordered  the  ammonio-citrate  of  iron  in  five-grain  doses  twice 
a  day  and  to  leave  the  hospital.  A  year  later  (April,  1877)  he 
was  in  perfect  health. 

Case  2. — This  case  presented  considerable  interest,  and  when 
sent  to  me  an  abscess  communicated  with  the  left  lung  and 
pleura. 

B.  M — ,  set.  3,  a  fair  and  very  intelligent  child,  was  admitted 
into  the  Samaritan  Hospital,  under  my  care,  on  December  22d, 
1876.  The  mother  stated  that  the  child  had  been  ailing  with 
bronchitis  and  cough  ever  since  the  previous  September,  and  had 
not  enjoyed  a  day's  health  since.  There  was  no  history  of  an  acute 
illness;  on  the  other  hand,  the  symptoms  were  gradual,  and  at  no 
time  marked  by  fever  or  inability  to  leave  her  bed.  On  examina- 
tion there  was  a  prominent  and  circumscribed  swelling  on  the  left 
side,  over  the  lower  ribs,  about  two  inches  below  the  nipple.  On 
auscultation  there  was  considerable  dulness  and  imperfect  expan- 
sion below  the  left  clavicle;  the  voice  was  bronchophonic  and  the 
respiration  harsh  and  bronchial.  The  heart's  sounds  were  distinctly 
heard  throughout  the  thorax.  Posteriorly  the  dulness  extended 
downwards  to  the  middle  of  the  scapula,  and  the  note  was  not  at 
all  clear  below  this ;  the  respiration  was  dry  and  harsh.  There  was 
scarcely  any  cough  to  speak  of,  and  the  temperature  was  normal, 
but  the  pulse  was  160,  small  and  weak  ;  the  respirations  56,  short 
and  catching;  the  bowels  regular  and  the  urine  free  and  clear. 
A  poultice  was  ordered  to  the  swelling,  and  a  grain  of  carbonate 


PNEUMONIA.  469 

of  ammonia  in  tincture  of  cinchona  every  four  hours.*  The  diet 
consisted  of  beef  tea,  milk,  and  two  eggs  daily,  beaten  up  with 
sherry.  On  the  24th  the  abscess  was  opened  and  a  small  quantity 
of  laudable  pus  escaped  ;  the  child  had  slept  tranquilly,  without 
cough,  but  the  pulse  was  very  weak  and  small.  On  the  2Gth  the 
temperature  was  98°,  pulse  128,  respiration  48.  The  abscess  had 
discharged  a  large  quantity  of  matter  in  the  night,  and  this  had 
given  her  ease;  she  sat  up  in  bed  and  was  aware  of  all  that  went 
on  around  her,  but  she  was  peevish  and  fretful,  and  looked  very 
pallid  and  exhausted.  The  upper  third  of  the  left  lung  was  very 
dull  posteriorly,  and  the  breathing  dry,  shrill,  and  tubular,  but 
descending  downwards  these  physical  signs  became  less  marked, 
though  everywhere  they  presented  a  striking  contrast  to  the  oppo- 
site side.  On  the  28th  the  pulse  was  96,  respiration  32;  the  ab- 
scess was  discharging  freely  and  there  w^as  no  cough;  over  the 
lower  lobe  on  the  left  side  the  percussion-note  was  becoming  reso- 
nant, and  the  dry  breathing  was  supplanted  by  coarse  crackling 
respiration.  On  January  4th,  1877,  the  respiration  was  clearer 
under  the  left  clavicle,  but  still  showed  a  marked  contrast  to  the 
opposite  side;  posteriorly  the  dulness  was  diminished,  and  in  the 
lower  half  of  the  lung  the  moist  rales  were  nearly  absent,  whilst 
in  the  centre  of  the  lung  the  voice  was  bronchophonic.  A  mixture 
of  iron,  carbonate  of  ammonia,  and  a  very  small  dose  of  iodide  of 
potassium  was  ordered  three  times  a  day.f  On  the  19th  the  ab- 
scess reformed,  and  it  was  necessary  to  make  a  counter-openino-. 
On  March  2d  the  patient  had  gained  a  stone  in  weight  since  ad- 
mission under  the  effect  of  good  diet,  cod-liver  oil,  and  the  syrup 
of  iodide  of  iron.     The  patient  shortly  after  sickened  for  measles, 


gr.  viij 

3iij 

5  iv.— M. 


*  Formula  71 : 

B.  Tinct.  cinch,  co.,       ........     ^iiss. 

Amm.  carb.,     ..... 

Tinct.  campli.  co.,    .... 

Syr.  tolut., 

Aqnam  ad        ....         . 
A  dessertspoonful  every  four  hours.     For  children  five  or  six  years  old. 
f  Formula  72  : 

R.  Ferri  et  amm.  citr., '  .         .        .     gr.  xij 

Amm.  carb.,       .........     gr.  viij 

Potass,  iodidi, .         .     gr.  iv 

Syrupi, 3ij 

Aquam  ad ^iv. — M. 

A  dessertspoonful  to  be  taken  three  times  a  day.     For  children  five  or  six  years  old. 


470  DISEASES    OF    CHILDEEX. 

and  was  consequently  detained  in  hospital  till  April  13tli,  when 
the  wound  had  soundly  cicatrized,  and  no  difference  could  be  dis- 
covered in  the  physical  signs  of  either  lung,  which  presented  every 
sign  of  health. 

Chronic  pneumonia  appears  to  be  sometimes  caused  by  disease 
of  the  tracheal  and  bronchial  glands.  Dr.  Gee  has  related  some 
interesting  cases.*  Measles,  scarlet  fever,  pertussis,  and  chronic 
cough  were  the  causes  of  the  glandular  affection.  In  one  case 
(aged  3  years  9  months}  a  cavity  in  the  bronchial  glands  was  found, 
containing  a  slough,  which  opened  into  the  oesophagus  and  left 
bronchus;  the  tracheal  glands  were  enlarged  and  caseous;  the 
riccht  lung;  was  studded  with  miliary  tubercles.  In  a  second  case 
(aged  6  years)  the  bronchial  glands  at  the  bifurcation  of  the  trachea 
were  transformed  into  a  cheesy  mass  ;  the  right  bronchus  was  per- 
forated by  an  ulcer.  There  was  hectic  fever  during  illness.  In  a 
third  case  (9  years  old)  at  the  bifurcation  of  the  trachea  there  was 
a  sloughing  cavity,  and  the  right  bronchus  opened  into  it ;  the 
right  lung  was  entirely  solidified;  there  was  hectic  fever  through- 
out the  illness.  In  a  fourth  case  (aged  2|  years)  the  tracheal 
glands  compressed  the  lung,  and  on  section  the  tumor  contained 
a  cavitj',  the  size  of  a  walnut,  filled  with  thick  creamy  pus.  The 
bronchial  glands  were  also  enlarged. 

(Edema  of  the  lungs^  though  rare  in  children,  is  of  sufficient  im- 
portance and  frequency  to  deserve  careful  consideration.  There 
is  no  evidence  of  inflammation  in  the  tissue  of  the  lungs,  but  it 
is  infiltrated  with  watery  fluid,  so  that  it  is  firm  and  inelastic;  it 
contains  very  little  air,  scarcely  crepitates,  and  sinks  in  water. 
On  examination  of  the  lungs  after  death  there  may  be  found  an 
effusion  of  clear  serum  into  the  cavity  of  the  pleura,  or  even  a  thin 
layer  of  lymph,  proving  that  some  degree  of  inflammation  has  taken 
place.  The  lungs  are  of  a  deep-red  color.  On  cutting  into  their 
substance  reddish  serum  exudes,  and  as  it  escapes  the  pulmonary 
tissue  becomes  crepitant  and  lighter  in  color.  The  air-cells  and 
pulmonary  connective  tissue  contain  so  much  fluid  that  it  inter- 
feres with  the  free  entrance  of  air,  and  explains  the  cause  of  the 
rapid  and  difficult  respiration.  "  This  is  a  condition  very  frequently 
found  in  Bright's  disease,  or  where  there  is  a  disposition  to  dropsy  ; 
the  lung  is  found  filling  the  chest  and  heavy,  and  on  a  section 

*  On  the  Chronic  Pneumonia  which  attends  Disease  of  the  Tracheal  and  Bronchial 
Glands,  St.  Barth.  Hosp.  Rep.,  vol.  xiii,  p.  G3. 


PNEUMONIA.  471 

beino;  made  a  quantity  of  serum  drains  out,  leaving  the  tissue 
healthy  and  firm.  It  is  thus  distinguished  from  the  first  stage 
of  inflammation,  in  which  the  texture  is  very  lacerahle."* 

Causes. — We  may  attribute  this  peculiar  state  in  most  cases  to 
a  passive  or  mechanical  obstacle  to  the  free  circulation  of  the 
blood,  as  in  pneumonia,  valvular  disease  of  the  heart,  and  pressure 
on  the  pulmonary  veins.  "  Laennec  taught  that  pulmonary 
oedema  may  occur  as  a  primary  and  idiopathic  condition,  and  that 
the  suftbcative  orthopnoea,  which  sometimes  cuts  ofi:' children  after 
measles,  arises  from  such  oedema. "f  Cases  have  resulted  from 
anasarca  after  scarlatina,  from  morbid  states  of  the  blood,  as  in 
Bright's  disease,  purpura,  and  the  continued  fevers.  I  have  seen 
two  cases  which  occurred  as  the  consequence  of  constitutional 
debility,  and  a  low  state  of  the  general  health.  Both  were  pre- 
ceded b}^  slight  catarrh  (a  subacute  form  of  bronchitis),  and  no 
alarm  was  realized  till  the  respiration  became  rapid,  out  of  all 
proportion  to  the  pulmonary  state.  The  condition  is  one  not  only 
associated  with  debility  and  relaxation  of  the  vessels  and  tissues, 
but  the  quality  of  the  blood  has  probably  undergone  a  change 
similar  to  what  occurs  in  passive  dropsy.  It  is  thinner  and  more 
watery  than  in  health,  the  corpuscles  and  organic  matters  are 
diminished,  and  hence  the  transudation  of  the  serous  parts  through 
the  vessels  and  capillaries. 

The  physical  signs  which  indicate  this  condition  are  not  very 
characteristic  or  reliable  ;  there  is  some  dulness  on  percussion,  and 
increase  of  vocal  fremitus  ;  the  respiration  is  weak  and  often  mixed 
with  rather  loose  rales  and  subcrepitant  rhonchus  ;  "  the  fine  bub- 
bling rhonchus.  when  very  liquid  and  well  marked,  is  the  most 
characteristic  sign.":{; 

Treatment. — This  will  depend  upon  the  cause.  If  the  disease 
comes  on  during  the  anasarca  of  scarlet  fever,  the  hot-air  bath, 
and  diaphoretics  to  act  on  the  skin  will  be  needed  to  remove  renal 
congestion.  Small  doses  of  tartarated  antimony  and  spirit  of 
nitrous  ether  will  relieve  the  dj'spnoea,  whilst  a  poultice  may  be 
necessary  if  the  bronchial  congestion  is  suflicient  to  demand  it. 
But  it  often  happens  that  oedema  of  the  lungs,  coming  on  gradu- 
ally in  strumous  and  delicate  children,  demands  a  supporting  line 

*  Wilks  and  Moxon,  Pathological  Anatomy,  1875,  p.  323. 

t  Disenses  of  the  Lungs  and  Heart,  by  W.  H.  Walshe,  M.D.,  1854.  p.  448. 

X  Walshe,  op.  cit.,  p.  449. 


472  DISEASES    OF   CHILDREN. 

of  treatment,  as  spirit  of  chloroform,  ammonia,  brandy,  and  good 
nourishment. 


CHAPTER    XXXIX. 

ON    TUBERCULOSIS. 

Nature  and  Definition  of  Tuberculosis.  Artificial  Production  of  Tu- 
bercle. Gray  and  Yellow  Varieties.  Anatomical  Characters  and 
Appearances  found  in  the  Lungs  in  Tuberculosis.  Comparative  Fre- 
quency OF  Tubercle  in  the  various  Organs  of  the  Body.  Usual  Prog- 
ress OP  Tuberculosis.  Causes:  Hereditary  predisposition — Influence  of  age — 
External  causes,  as  bad  air  and  ventilation — Insufficient  food — Chronic  diarrhoea  and 
indigestion — The  eruptive  fevers  and  whooping-cough — Inflammation  an  exciting  cause 
of  tuberculosis.  Symptoms  :  Pain  in  epigastrium  and  indigestion — Temperature  of 
the  body  in  tuberculosis  the  surest  means  of  diagnosis  in  the  absence  of  physical  signs — 
Sweating,  pulse,  and  respiration  as  diagnostic  aids— Illustrative  cases  which  may  bemis- 
takenfor  tuberculosis. 

By  the  term  tuberculosis  we  mean  a  general  condition  of  ill- 
health,  attended  with  the  deposition  of  tubercle  in  one  or  more 
organs  of  the  body.  It  is  a  constitutional  febrile  affection,  which 
is  usually  associated  with  inflammatory  action  in  the  lungs,  bron- 
chial glands,  cerebral  meninges,  and  peritoneum.  We  say  asso- 
ciated., because  its  precise  relation  to  inflammation,  whether  as  a 
mere  variety  or  as  a  concomitant,  or  a  result,  is  still  a  great  patho- 
logical question,  which  we  will  discuss  further  on.  In  childhood 
it  has  some  special  and  characteristic  symptoms  which  we  do  not 
observe  in  later  life,  and  the  causes  and  history  have  a  separate 
and  distinct  character.  In  well-marked  cases  of  tuberculosis  the 
children  are  usually  good-looking,  with  prominent  veins,  long  eye- 
lashes, and  dilated  pupils  ;  the  figure  is  erect  and  slim,  the  joints 
are  small  and  slender,  and  the  shafts  of  the  bone  thin  and  straight ; 
the  growth  of  mind  and  body  is  active,  and  the  nervous  system  is 
highly  impressible ;  the  child  is  sensitive  to  reproof  or  kindness, 
quick  and  clever  at  lessons,  and  does  not  exhibit  the  backwardness 
which  belongs  to  the  phlegmatic  temperament.  These  children 
are  not  subject  to  enlargement  of  the  lymphatic  glands,  nor  have 
they  the  thick  lips  and  dull  expression  of  the  truly  scrofulous 
diathesis.  Tuberculosis,  then,  or  the  tuberculous  cachexia,  sig- 
nifies that  state  of  constitution  which  arises  from  the  presence  of 
tubercles  ;  and  by  tubercles  is  meant  a  species  of  new  matter,  or 


ON  TUBERCULOSIS.  473 

growth,  prone  to  degeneration  and  decay.  In  its  crude  condition 
it  resembles  concrete  albumen,  and  consequently  becomes  soft  and 
friable,  and  acquires  the  consistence  and  appearance  of  thick  cream, 
or  cheese,  or  pus.  But  a  variety  of  circumstances  will  determine 
the  character  of  the  exudation,  and  it  may  abound  in  elements  at 
one  time  which  are  not  to  be  detected  in  it  at  another.  It  is  de- 
posited upon  the  surface  of  the  mucous  membrane  of  the  air-cells, 
or  within  the  parenchymatous  structure  of  the  lungs,  where,  in- 
stead of  being  absorbed  or  excreted,  as  happens  in  the  simple  exu- 
dative inflammations  of  the  healthy,  it  slowly  degenerates  by 
reason  of  its  inherent  faulty  con'.position  and  deficient  vitality. 
This  question  is  discussed  further  on.  Tubercles  are  the  local  ex- 
pression of  a  depraved  constitutional  state,  and  most  likely  repre- 
sent enfeebled  nutritive  energy.  When  few  in  number  they  occa- 
sionally become  hard  and  indurated,  and  do  not  interfere  with  the 
organic  functions ;  but  when  they  are  numerous  they  affect  the 
general  health,  and  if  deposited  in  the  lungs,  cause  in  most  in- 
stances an  alteration  in  the  physical  signs,  and  lead  to  softening 
and  suppuration  of  the  tissues  in  which  they  are  deposited.  The 
gray  and  yellow  varieties  are  the  kinds  with  which  we  are  familiar. 
Under  the  microscope  a  section  of  a  miliary  or  recent  tubercle 
shows  numerous  leucocytes  generally  included  in  a  network  of 
delicate  fibres — the  '•'•adenoid  tissue^'  seen  in  glands.  In  the  centre 
of  the  tubercle  are  large  multinucleated  cells,  sometimes  called 
'■'•giant  cells"  the  processes  of  which  are  directly  continuous  with 
the  reticulum.  The  caseous  tubercle  shows  cells  in  all  stages  of 
deo;eneration  and  disintegration. 

Tubercular  exudation  is  most  commonly  met  with  in  children 
and  young  adults.  It  occurs  in  the  lymphatic  glands,  the  lungs, 
and  serous  membranes,  and  its  progress  is  generally  slow  and  in- 
sidious ;  but,  on  the  other  hand,  it  is  sometimes  rapidly  roused 
from  latency  into  activity,  or  set  up  anew  by  some  commonplace 
disorder.  There  is  no  attempt  at  absorption  or  perfect  cell  forma- 
tion, but  a  tendency  to  ulceration  and  disintegration,  with  a  cer- 
tain train  of  general  symptoms,  recognized  by  failing  health  and 
strength,  and  persistent  derangement  of  the  digestive  functions. 

According  to  Virchow,  although  tubercle  is  the  result  of  the 
death  of  healthy  or  diseased  tissues,  the  local  process — tuberculosis 
— also  results  in  the  exudation  of  a' material  during  tuberculous 
inflammation ;  such  material  undergoing  a  kind  of  organization, 


474  DISEASES    OF    CHILDEEJST. 

succeeded  by  its  death,  and  by  its  breaking  and  shrivelling  up 
into  a  tubercle.  This  gradual  change  is  termed  tuberculization,* 
There  is  much  evidence  to  be  adduced  in  support  of  that  theory 
which  classifies  tubercle  as  a  primary  formation,  like  cancer  and 
epithelial  and  melanotic  growths.  All  the  changes  that  take 
place  are  secondary,  and  without  the  presence  of  malnutrition  it 
seems  highly  probable  that  no  lesion  can  produce  it.f 

The  conditions,  then,  under  which  tuberculosis  originates  are 
not  precisely  known,  as  low  inflammatory  products  may  cause  in- 
duration or  suppuration,  and  yet  the  disease  may  not  be  developed. 
It  is  not  known  whether  the  disease  is  specific  or  not,  or  how  it  is 
generated  within  the  body.  When  the  sputa  of  phthisical  patients 
have  been  given  to  dogs  and  poultry,  tuberculosis  has  sprung  up; 
and  the  same  has  been  the  case  with  cattle  fed  with  tubercular  or 
scrofulous  products.^  Villemin  was  the  first  to  show,  by  a  series 
of  experiments,  that  when  finely  divided  masses  of  gray  or  yellow 
tubercle  were  introduced  under  the  skin  of  guinea-pigs,  rabbits, 
and  some  other  animals,  a  local  form  of  inflammation  ensued,  and 
at  the  end  of  two  or  three  weeks  miliary  tubercles  were  discovered 
in  the  lungs,  and  at  a  later  period  in  the  intestines  and  peritoneum. 
Villemin,  therefore,  concluded  that  it  was  possible  to  propagate 
tuberculosis  by  inoculation,  in  the  same  way  that  occurs  with 
small-pox  and  syphilis.  Many  pathologists  have  carried  out  Ville- 
min's  experiments,  and  they  have  arrived  at  precisely  the  same 
results;  whilst  Burdou  Sanderson  and  Wilson  Fox  made  the  fur- 
ther discovery  that  miliary  granulations  arose  in  some  of  the  chief 
organs  of  the  bodj^  when  pus,  putrid  tissue,  and  portions  of  a 
pneumonic  lung  were  introduced  subcutaneously.  Dr.  Burdon 
Sanderson'sg  experiments  on  the  artificial  production  of  tubercle 
in  the  lower  animals  throw  much  light  on  the  pathology  of  the 
aftection  as  it  occurs  in  man.  He  found  that  it  is  most  readily 
produced  in  the  guinea-pig,  next  in  the  rabbit,  and  lastly  in  the 
dog.  "For  three  reasons,"  says  Dr.  Sanderson,  "  the  guinea-pig  is 
preferable  ;  (1)  because  it  is  absolutely  free  from  liability  to  natural 
tubercle;  (2)  because  it  is  little  liable  to  acute  inflammation  ;  and 
(3)  because  it  can  be  inoculated  with  absolute  certainty."     An  in- 

*  Dictioiiiiry  of  Medical  Sciences  (Dimglison),  article  Tubercle,  1874,  p.  106'A 

f  Jones  and  Sieveking's  Pathological  Anatoin}^  by  Payne,  1875,  p.  203. 

X  See  The  Lancet,  Nov.  23d,  1878,  p.  741. 

§  Recent  Researches  on  Artificial  Tuberculosis,  Edin.  Med.  Journ.,  Nov.,  18C9. 


ON   TUBERCULOSIS.  475 

finitesimal  close  of  the  infective  material  is  taken  from  the  diseased 
gland  of  an  infected  animal,  and,  after  being  mixed  with  a  little 
distilled  water,  is  injected  into  the  peritoneum,  the  pleura,  or  sub- 
cutaneous areolar  tissue.  Drs.  Sanderson  and  Wilson  Fox,  in  1868, 
produced  tuberculosis  in  the  guinea-pig  by  the  insertion  of  setons 
and  non-tubercular  products.  An  abscess  followed  around  the 
foreign  body,  and  tuberculosis  supervened.  Professor  Cohnheim 
also  confirmed  these  experiments,  and  produced  tuberculosis  trau- 
matically  by  introducing  harmless  foreign  bodies  into  the  perito- 
neum. The  result  obtained  by  these  researches  was  to  produce 
nodules  of  new  growth,  having  a  lymphatic  structure,  and  termed 
lymphomas  hy  Virchow, because  they  are  commonly  found  in  cer- 
tain organs  of  the  lymphatic  system.  Dr.  Sanderson  proposes  the 
term  adenoid,  because  he  says  in  certain  parts  of  the  body  there 
are  organs  like  these  growths  we  are  considering  which  possess  a 
structure  identical  with  the  follicles  of  the  lymphatic  glands,  and 
that  where  they  exist  naturally,  as  beneath  the  pleura  and  perito- 
neum, there'  these  tubercular  nodules  or  overgrowths  are  most 
frequently  found.  These  nodules  or  tubercles  appear  in  fact  to  be 
nothing  more  than  overgrown  masses  of  pre-existing  tissue,  or  en- 
larged adenoid  bodies.* 

In  fact,  these  pathologists  ascertained  that  simple  mechanical 
irritation  set  up  the  sanie  morbid  process  as  the  inoculation  of  the 
specific  products  I  have  alluded  to.  Thus  it  seems  satisfactorily 
demonstrated  that  general  tuberculosis  may  arise  from  the  inocu- 
lation of  a  morbid  poison  into  a  wound,  or  from  the  absorption  of 
inflammatory  products ;  and  although  the  injection  of  tubercular 
matter  does  appear  to  induce  the  disease  with  greater  certainty  and 
celerity,  there  is  no  reason  whatever  to  suppose  that  any  specific 
inoculation  is  necessary.     These  carefully  conducted  experiments 

*  "  I  am  quite  willing  to  acknowledge  a  close  aflBnity  between  lymphatic  glandular 
swellings  and  tubercles,  for  they  affect  the  same  subjects  and  run  a  similar  course.  But 
these  glandular  swellings  also  have  a  close  resemblance  on  the  one  hand  to  swellings 
from  inflammation,  and  on  the  other  to  tlie  simple  enlargement  of  tlie  spleen  and  liver 
occurring  in  leukaemia.  In  both  these  cases  there  is  doubtless  hypertroi)hy  or  hyper- 
plasia, but  this  may  be  in  the  way  of  exudation  or  cell  pi-oliferation,  without  the  de- 
velopment of  complex  tissue  which  constitutes  agroivth.  If  the  addition  of  cells,  fibres, 
and  other  products  of  inflammation  in  a  tissue  constitutes  a  growth,  then  common 
cutaneous  pimples,  tubercles,  and  boils  are  growths,  and  the  swelling  from  erysipelas 
or  cellulitis  must  be  included  under  the  same  term  ;  but  this  surely  would  exceed  its 
usual  acceptation." — Pulmonary  Consumption,  by  Drs.  C.  J.  B.  and  C.  T.  Williams, 
1871,  p.  17. 


476  DISEASES   OF   CHILDEEX. 

have  had  a  surprising  eflect  in  modifying  our  views  regarding  the 
prevailing  doctrine  of  tubercle,  and,  as  we  shall  subsequently  see, 
they  have  an  important  practical  bearing.  It  decides  the  long- 
disputed  question  that  low  forms  of  simple  or  even  acute  inflam- 
mation in  some  subjects  may  eventuate  in  tubercular  disease, 
without  any  original  deposition  of  tubercle;  and  in  support  of 
this  view  I  may  allude  to  the  circumstance  that  neglected  pleuritic 
effusion  in  children  is  often  followed  by  empyema  and  occasionally 
by  tuberculosis.  A  common  cold  in  delicate  children,  or  those  pre- 
disposed to  the  affection,  will  now  and  then  give  rise  to  it ;  indeed, 
no  vascular  excitement  in  such  subjects  is  to  be  disregarded. 

With  regard  to  the  history  of  the  above  researches  it  may  be 
stated,  that  for  the  last  two  hundred  years,  tubercles  were  con- 
sidered to  be  allied  to  scrofulous  lymphatic  glands  till  the  time  of 
Bayle,  who  regarded  tubercle  as  a  peculiar  product,  and  the  result 
of  a  special  constitutional  diathesis, — a  deposit  depending  on  a 
morbid  state  of  the  blood.  Eayle  gave  the  name  of  tubercle  to 
the  gray  and  yellow  masses  which  he  found  in  the  lungs.  Virchow 
proved  that  yellow  caseous  matter  was  not  the  character  of  true 
tubercle,  and  that  it  might  arise  from  fatty  degeneration,  and  the 
products  of  pus,  and  cancer,  and  so  forth.  He  called  the  gray 
granulation  of  Cayle  the  typical  form  of  tubercle,  and  considered 
infiltrated  tubercle  and  caseous  masses  as  the  consequence  of 
inflammation.  Dr.  Wilson  Fox  entertains  the  view  that  the 
caseous  products  arising  in  the  lung  in  phthisis  are  due  to  the 
destruction  of  vessels  by  a  new  growth  in  the  walls  of  the  air- 
vesicles,  and  that  the  typical  gray  granulation  is  not  the  only 
form  in  which  tubercle  occurs.*  jSTiemeyer  considers  that  phthisis, 
as  a  disease,  has  nothing  to  do  with  tubercle,  which  is  only  an 
accidental  and  secondary  product  when  found  in  the  lung,  and 
the  result  of  inspissation  of  inflammatory  products,  leading  to 
destructive  and  ulcerative  changes  in  the  lung-tissue. 

Dr.  Fox's  researches  seem  to  show  that  the  changes  found  in 
the  lungs,  in  acute  tuberculosis  in  children,  are  the  same  as  those 
observed  in  the  ordinary  forms  of  phthisis. 

According  to  this  authority ,t  the  following  are  tlie  chief  appear- 
ances found  in  the  lungs  of  children  dying  of  acute  tuberculosis: 

*  Trans.  Path.  Soc,  1873,  vol.  xxiv,  p.  287. 

t  Discussion  on  the  Anatomical  Rehitions  of  Pulmonary  Phthisis  to  Tubercle  of  the 
Lung,  Trans.  Path.  Soc,  1873,  vol.  xxiv,  p.  291. 


ox    TUBERCULOSIS.  477 

"The  semi-transparent  granulation  of  Bayle.  Opaque  white 
granulations,  for  the  most  part  soft,  but  with  varying  degrees  of 
firmness  and  difficulty  of  crushing.  Granulations  like  the  semi- 
transparent  granulations  of  Bayle,  and  also  like  the  soft  granu- 
lations, hut  more  or  less  caseous  in  their  centres.  Yellow  soft 
granulations,  easily  crushed,  but  not  easily  removed  from  the 
pulmonary  tissue,  varying  in  size  from  that  of  a  poppy  seed  to  a 
mustard-seed,  rarely  of  the  size  of  a  hemp-seed,  and  slill  more 
rarely  of  the  size  of  a  split  pea.  Caseous  granulations,  dry,  opaque, 
and  friable;  sometimes  with,  sometimes  without,  a  gray  trans- 
parent zone  of  induration  surrounding  them.  Groups  of  granu- 
lations, mostly  like  the  semi-opaque,  sometimes  entirely  opaque, 
rarely  semi-transparent ;  two  or  three,  or  four,  or  more  in  number, 
reaching  the  size  of  a  split  pea,  or  a  bean,  or  even  a  small  walnut, 
or  hazelnut.  Indurated  pigmented  granulations,  singly  or  in 
groups,  like  the  last  described.  And  lastly,  tracts  of  indefinite 
extent,  one  or  two  or  more  inches  in  diameter,  irregular  in  outline, 
prominent  above  the  surface,  granular  on  section  or  tearing  of  the 
tissue,  but  passing  sometimes  insensibly  into  the  so-called  gray 
infiltration.  Cavities,  from  infinitesimal  specks  to  the  size  of  a 
hazelnut  or  larger.  Granulations  softening  into  cavities — either 
the  softer,  the  white  or  the  yellow.  The  semi-transparent  granu- 
lation in  the  lung  is  not,  as  far  as  I  have  seen,  found  softening 
into  a  cavity  without  some  intermediate  change.  Tracts  of  gray 
semi-transparent  appearance,  known  as  the  '  gray  pneumonia  '  or 
'gelatinous  pneumonia,'  or  'gray  infiltration,'  or  gelatinous  infil- 
tration of  Laennec  ;  spots  also  of  red  pneumonia ;  in  some  cases 
cedema ;  in  some  cases  injection  or  punctiform  extravasation  ;  in 
some  cases  emphysema  and  collapse  ;  in  some  cases  capillary  bron- 
chitis and  dilatation  of  bronchi.  The  point  on  which  I  Avish 
especially  to  insist  is,  that  the  gray  granulation  of  Bayle  is  very 
seldom  found  alone.  They  are  sometimes  found  as  isolated  struc- 
tures scattered  throughout  the  whole  lung,  but  this  is  compara- 
tively rare.  In  the  combinations  of  eleven  cases  they  were  only 
found  alone  in  two.  They  either  coexisted  with  caseous,  or  with 
the  white  and  the  soft,  or  with  the  caseous,  or  with  the  soft  and 
caseous,  or  with  the  indurated,  or  with  the  soft,  yellow,  and 
caseous,  or  with  the  soft  and  caseous  alone ;  most  of  these  being 
combined  either  with  red  or  gray  pneumonia,  or  with  tracts  of 
caseous  infiltration.     Those  are  the  forms  of  the  combinations  of 


478  DISEASES   OF    CHILDEEX. 

which  I  made  notes  in  eleven  cases  that  died  under  my  own  obser- 
vation. The  gray  granulation  of  Bayle,  the  typical  tubercle  of 
Yirchow,  does  not  therefore  exist  alone  in  the  majority  of  cases 
of  acute  tuberculosis  in  the  lungs  of  children.  It  is  most  com- 
monly associated  with  other  granulations,  which  have  a  difierent 
appearance  to  the  naked  eye,  and  also  a  difierent  anatomical 
structure;  and  the  latter,  in  some  cases,  are  the  predominaut 
change,  so  that  in  some  lungs  the  gray  granulation  is  compara- 
tively rare." 

UnUke  the  case  of  adults,  gray  granulations  and  crude  miliary 
granulations  frequently  exist  in  children  as  the  only  form  of  tuber- 
cular deposit.  In  the  adult,  M.  Louis  discovered  miliary  tubercles 
alone  in  2  out  of  123  cases  (1.6  per  cent.),  and  gray  granulations 
alone  only  in  5  more  (4  per  cent.).  In  the  child,  Rilliet  and  Barthez 
found  miliary  tubercles  without  gray  granulations  in  107  cases 
out  of  265  cases,  and  gray  granulations  alone  in  36  out  of  the  same 
number  of  cases.  In  102  cases  of  phthisis  in  children.  Dr.  West* 
found  miliary  tubercles  alone  in  the  lungs  in  20  instances,  and 
gray  granulations  alone  in  17  more.  Another  anatomical  pecu- 
liarity in  early  life  is  the  great  frequency  of  yellow  infiltrated 
tubercle.  It  seldom  exists  alone,  but  is  generally  associated  with 
crude  yellow  tubercle  and  gray  granulations,  and  sometimes  with 
advanced  disease  of  the  bronchial  glands.  Rilliet  and  Barthez 
met  with  it  in  88  out  of  265  children,  or  in  33  per  cent,  of  their 
cases. 

As  to  the  frequency  with  which  we  meet  with  tubercle  in  the 
difierent  organs  in  the  body,  Steiner  found  the  intestine  involved 
in  a  third  of  all  his  cases;  the  most  frequent  seat  being  the  small 
intestine,  and  the  least  frequent  the  large.  From  302  dissections 
made  in  the  Prague  Hospital  by  Drs.  Steiner  and  Neureulter 
tubercle  was  found 

In  1  organ   in  42  cases.  In  5  organs  in  42  cases 

In  2  organs  in  48     "  In  6       "       in  28     " 

In  3      "       in  62     "  In  7       "       in  20     " 

In  4      "       in  47     "  In  8       "      in    6     " 

Five  times  in  nine  cases,  and  twice  in  ten  different  organs. 

The  bronchial  glands  were  affected  in  275  cases,  the  lungs  in  175, 
and  the  stomach  in  4.f     In  812  children  in  whom  Rilliet  and  Bar- 

*  Diseases  of  Infancy  and  Childhood,  4th  edition,  1859,  p.  448. 
f  Steinei-'s  Diseases  of  Children,  by  Lawson  Tait,  1874,  p.  328. 


ox   TUBERCULOSIS.  479 

tliez  found  a  deposit  of  tiil)ercle  in  one  or  more  of  the  viscera,  the 
kings  -were  heaUhy  in  47  cases  ;  whilst  in  123  simihir  instances  in 
the  adult,  Louis  only  found  one  such  exception.* 

Dr.  Wilson  Fox  mentions  61  cases  which  he  examined  for  the 
chief  purpose  of  illustrating  the  pulmonary  manifestations  of  the 
disease.  All  were  ahove  ten  years  of  age,  and  only  2  below  fifteen 
and  two  ages  not  stated.  In  all  the  cases  hut  one  the  lungs  were 
afiected,  and  in  this  was  a  combination  of  tubercular  pleurisy  with 
tubercular  peritonitis.  In  7  cases  the  data  were  uncertain;  in  3 
cases  the  disease  was  limited  to  the  lungs ;  in  7  cases  two  organs 
were  affected;  in  16  cases  three  organs;  in  12  cases  four  organs; 
in  9  cases  five  organs ;  in  6  cases  six  organs ;  in  1  case  seven 
organs. f 

M.  Louis  entertained  the  opinion  that  when  tubercle  appeared 
in  any  part  of  the  body  it  was  sure  to  exist  in  the  lungs  also,  and 
that  the  apices  of  these  organs  were  the  selected  seat  of  deposit. 
AVe  now  know  that  this  is  by  no  means  the  universal  law,  which 
the  propounder  considered  he  had  established,  but  it  holds  good 
with  a  few  "exceptions,  and  is  of  vast  assistance  in  diagnosis.  I 
have  heard  it  asserted,  and  I  have  also  seen  it  in  books,  that  in 
every  case  of  tubercular  meningitis  j'ou  will  find,  on  examination 
alter  death,  evidence  of  tubercle  in  the  lungs,  kidneys,  peritoneum, 
or  spleen ;  but  twice  I  have  made  a  post-mortem  of  this  well- 
developed  cerebral  aflection  without  finding  a  trace  of  the  peculiar 
exudation  in  any  other  organ  or  tissue  of  the  body. 

The  sudden  manner  in  which  tubercular  disease  sometimes 
springs  up  without  any  obvious  exciting  cause,  is  alarmingly  sug- 
gestive that  an  over-excited  or  ill-nourished  organ  may  initiate 
the  peculiar  deposition  in  the  track  of  the  bloodvessels,  and  there 
set  up  decay  and  destruction,  having  no  inclination  to  spread  and 
contaminate  other  organs  and  tissues.  Dr.  Fox  mentions  a  case 
recorded  by  Ilerard  and  Cornil,  in  which  the  disease  was  limited 
to  a  single  lung,  and  he  S2:)eaks  of  three  other  recorded  cases 
where,  in  addition  to  other  lesions,  one  lung  was  aftected,  and  the 
other  remained  free. 

It  was  long  held  that  when  tubercle  was  deposited  in  the  lungs 
it  would  sooner  or  later  proceed  to  a  fatal  issue;  but  repeated  ex- 
amination goes  to  prove  that  it  is  sometimes  spontaneously  arrested, 

*  IMeigs  and  Pepper's  Diseases  of  Children,  1874,  p.  843. 
t  Trans.  Path.  Soc,  1873,  vol.  xxiv,  p.  375.  . 


480  DISEASES   OF   CHILDEEN. 

and  it  has  been  said  that  tliis  happens  in  one-third  of  the  persons 
aiiected  with  tuberculosis.  This  is  confined  to  no  stage  or  period 
of  the  disease;  it  may  be  stopped  in  the  early  stages  when  the 
deposit  is  small  and  trifling,  and  instances  are  met  with  w^here 
large  cavities  have  healed  and  cicatrized.  "  Nothing  is  more  com- 
mon," says  the  late  Dr.  Ilughes  Bennett,*  "in  examining  dead 
bodies  than  to  meet  with  cretaceous  and  calcareous  concretions  at 
the  apices, of  the  lungs  more  or  less  associated  Avith  cicatrices.  Of 
73  bodies,  which  I  examined  consecutively  some  years  ago  in  the 
Royal  Infirmary,  I  found  these  lesions  in  28.  Of  these,  puckerings 
existed  with  induration  alone  in  12  ;  with  cretaceous  or  calcareous 
concretions,  in  16.  Since  then  I  have  examined  many  hundred 
lungs  at  the  inspections  in  the  infirmary,  and  am  satisfied  that 
these  proportions  exist  pretty  constantly.  At  the  Salpetriere 
Hospital,  in  Paris,  Roger  found  them  in  51  bodies  out  of  100;  at 
the  Bicetre  Hospital,  in  the  same  city,  Boudet  found  them  in  116 
out  of  135  bodies."  In  1868  a  young  man  who  had  a  vomica  in 
the  apex  of  the  left  lung,  brought  me  from  time  to  time  portions 
of  calcareous  matter,  the  size  of  a  pea,  which  he  coughed  up  with 
expectoration.  He  was  greatly  reduced  in  flesh  and  strength,  but 
when  I  saw  him,  five  years  afterwards,  he  had  improved  in  every 
respect,  and  the  cavity  in  the  lung  was  apparently  contracting. 
I  met  with  a  similar  case  in  1874,  and  the  patient  was  living  in 
1878,  and  in  health. 

The  following  facts,  according  to  Dr.  Bennett,  are  proof  of 
arrested  tubercle: 

"  1.  A  form  of  indurated  tubercle  is  frequently  met  with,  gritty 
to  the  feel,  which,  on  being  dried,  closely  resembles  cretaceous 
concretions. 

"  2.  These  concretions  are  found  exactly  in  the  same  situation 
as  tubercular  deposits  are.  Thus  they  are  most  common  in  the 
lungs,  and  at  their  apices. 

"  3.  When  the  lung  is  the  seat  of  tubercular  infiltration  through- 
out, whilst  recent  tubercle  occupies  the  inferior  portion,  and  older 
tubercle  and  perhaps  caverns  the  superior,  the  cretaceous  and 
calcareous  concretions  will  be  found  at  the  apex. 

"4.  A  comparison  of  the  opposite  lungs  will  frequently  show, 

*  Braitliwaite's  Retrospect,  vol.  xlvii,  1863,  p.  55. 


ON   TUBERCULOSIS.  481 

that  whilst  on  one  side  there  is  firm  encysted  tnbercle,  partly 
transformed  into  cretaceous  matter,  on  the  other  the  transforma- 
tion is  perfect,  and  has  occasionally  even  passed  into  a  substance 
of  stony  hardness. 

"  5.  The  puckerings  found  without  these  concretions  exactly 
resemble  those  in  which  they  exist.  Moreover,  whilst  puckering 
with  gray  induration  may  be  found  at  the  apex  of  one  lung,  a 
puckering  surrounding  a  concretion  may  be  found  in  the  apex  of 
the  other. 

"  6,  The  seat  of  cicatrices  admits  of  the  same  exceptions  as  the 
seat  of  tubercles,  and  in  about  the  same  proportion.  There  can 
be  no  question,  therefore,  that  these  cicatrices  and  concretions  for 
the  most  part  indicate  the  arrestment,  disintegration,  and  trans- 
formation of  pre-existing  tubercular  exudation  into  the  lungs." 

Causes. — Of  the  causes  of  tuberculosis,  and  the  deposition  of 
tubercles  in  the  lungs,  the  progress  of  medical  science  has  not  yet 
enabled  us  to  speak  with  any  degree  of  certainty;  and  the  same 
may  be  said  of  that  variety  of  disease  classified  under  the  compre- 
hensive term  scrofula,  with  its  external  abscesses  and  disfiguring 
ulcerations.  It  is  very  difficult  to  assign  the  correct  value  to 
hereditary  transmission  from  parent  to  offspring,  regarded  as  a 
predisposing  cause  of  tuberculosis,  because  a  large  proportion  of 
the  population  is  subject  to  anti-hygienic  conditions,  which  call 
the  disease  into  existence.  The  lives  of  so  many  young  persons 
are  passed  in  these  days  of  hard  toil  under  such  unhealthy  condi- 
tions that  it  is  readily  acquired.  What  is  gleaned  from  parents 
respecting  their  family  history  is  frequently  vague  and  deceptive. 
Some  will  tell  you  that  consumption  is  not  known  among  them, 
when  closer  investigation  satisfies  us  that  some  member  of  it  has 
suffered  from  hip-joint  disease,  open  abscesses  in  the  neck,  and 
even  fatal  affections  of  the  head  which  must  have  had  a  strumous 
origin.  Instances  of  hereditary  transmission  are  constantly  seen 
in  the  emaciated  frame  of  the  infant  whose  consumptive  mother 
barely  survives  the  birth.  When  the  child  dies,  the  lungs  and 
other  internal  organs  are  so  studded  with  tubercles  that  little 
doubt  can  be  entertained  that  the  disease  originated  at  the  earliest 
period  of  utero-gestation.  It  may  be  laid  down  as  a  law,  having 
few  exceptions,  that  the  union  of  healthy  parents  results  in  the 
birth  of  healthy  children,  and  that  they  grow  up  to  be  strong  and 
vigorous ;  but  that  when  one  parent  is  tuberculous  and  the  other 

31 


482  DISEASES   OF   CHILDREX. 

healtli}',  tuberculosis  is  apt  to  show  itself  in  the  offspring.  As 
the  children  one  after  another  reach  a  certain  age  thej  begin  to 
lose  flesh  and  strength,  and  at  last  die  with  all  the  sj-mptoms  of 
pulmonary  phthisis,  or  tubercular  disease  in  some  other  organ. 
The  best  explanation  for  this  large  class  of  cases,  which  we  observe 
where  the  victims  have  been  carefully  shielded  from  exhausting 
or  depresing  influences,  is  to  be  found  in  a  blood  djscrasia  or  some 
chano-es  in  the  vessels  or  tissues. 

Youth  is  one  of  the  most  fertile  predisposing  causes  of  tubercu- 
losis, the  blood  in  childhood  having  a  great  susceptibility  to  un- 
dergo those  changes  which  constitute  the  peculiar  pathological 
transformation.  TVe  can  only  conjecture  what  the  specific  change 
is  ;  but  we  do  know  that  in  early  life  the  blood  is  deficient  in  solid 
constituents,  and  in  blood-corpuscles.  As  children  grow  to  ma- 
turity, and  life  advances,  the  quality  of  the  circulating  fluid  is 
enriched,  the  tendency  to  tubercular  change  becomes  less  and  less, 
and  the  power  of  arrest  or  elimination  is  acquired  if  the  constitu- 
tional strength  can  be  maintained.  It  may  be  that  the  diminished 
number  of  red  corpuscles  in  chlorosis  and  antemia  is  one  reason  of 
their  fatal  termination  being  frequently  accompanied  by  the  de- 
posit of  tubercle  and  the  gradual  development  of  phthisis. 

The  effect  of  intermarriages  has  been  well  pointed  out  by  Sir 
William  Jenner.  "  That  tuberculosis  is  transmitted  from  parent 
to  child  is  one  of  the  Vjest  established  facts  in  medicine.  The  ex- 
treme frequency  of  tubercular  diseases  in  some  circumscribed 
country  districts  is,  in  part  at  least,  explicable  by  the  frequency 
of  intermarriage  amongst  persons  living  in  such  districts ;  and 
conversely,  the  exception  of  particular  circumscribed  districts  from 
tubercular  disease  is  due  to  the  same  cause.  In  one  case,  from 
some  special  circumstance,  tuberculosis  has  been  introduced  into 
the  district,  and  then  spread  in  it  from  the  cause  I  have  mentioned, 
i.  e.,  intermarrying;  in  the  other  case,  the  freedom  from  the  dis- 
ease of  the  district,  at  any  given  time,  is  the  cause  of  its  continued 
freedom.  Intermarriage  of  the  inhabitants,  the  disease  being  ab- 
sent, prevents  its  introduction."* 

Where  hereditary  transmission  is  so  strong  (and  that  it  is  so 
daily  experience  affords  the  most  conclusive  evidence),  the  germ  of 
the  disease  either  lies  in  a  latent  state,  or  is  actively  transmitted 
by  the  parent.     Rilliet  and  Barthez  furnish  some  interesting  facts 

*  Address  before  the  Epidemiological  Society  of  London,  1866. 


ON   TUBERCULOSIS.  483 

to  the  effect  that,  "  of  20  cliildren  whose  fathers  were  tuberculous, 
or  probably  so,  22  died  tuberculous,  and  4  non-tuberculous  ;  of  32 
children  whose  mothers  died  tuberculous,  or  probably  so,  22  died 
tuberculous,  and  10  non-tuberculous;  of  6  children  whose  fathers 
and  mothers  died  tuberculous,  4  died  tuberculous  and  2  non-tuber- 
culous. There  were  4fi  cases,  or  about  1  in  7,  in  which  the  heredi- 
tary influence  more  or  less  prevailed,  and  11  in  which  it  was  the 
sole  probable  cause."'''  There  are  many  points  of  extreme  interest 
on  this  part  of  the  subject,  such  as  the  relative  frequency  of  its 
transmission  by  the  two  sexes,  and  the  manner  in  which  this  takes 
place. 

Children  brought  up  by  hand,  and  weaned  too  soon,  or  neglected 
by  the  mother,  are  very  liable  to  the  disease.  A  case  is  related  by 
Meigs  and  Pepperf  of  a  healthy  woman,  who  had  several  vigorous 
children  whom  she  had  nursed.  She  gave  birth  to  one  which  she 
could  not  nurse,  and  this  child,  after  pining  for  many  months,  died 
of  tubercular  meningitis. 

Bad  or  insufficient  food,  leading  to  prolonged  indigestion  and 
diarrhoea,  exert  a  powerful  influence  in  the  production  of  tubercle. 
Artificial  foods  of  all  kinds,  when  too  exclusively  relied  on,  may 
awaken  the  disease  ;  and  defective  nutrition  and  mal-assimilation, 
however  brought  about,  are  common  causes  of  tuberculosis  in  those 
who  are  not  even  predisposed  to  the  aft'ection.  The  eruptive  fevers 
and  whooping-cough  frequently  act  as  a  starting-point,  the  disease 
having  an  admitted  tendency  to  spring  up  after  these  acute  affec- 
tions. The  continuance  of  febrile  action  is  liable  to  alter  and  de- 
teriorate the  quality  of  the  blood,  and  to  render  the  system  liable 
to  tubercular  deposit.  If  we  look  back  in  memory  only  to  our 
experience  of  the  number  of  children  who  have  exhibited  sjmnp- 
toms  of  tuberculosis,  as  the  consequence  of  febrile  disorders,  we  are 
in  a  great  measure  driven  to  embrace  the  doctrine  that  such  dis- 
eases as  whooping-cough  and  measles  not  unfrequently  originate 
the  disease  in  constitutions  not  hereditarily  tainted. 

In  those  cases  in  which  pneumonia  and  bronchitis  are  associated 
with  tuberculosis,  it  is  a  disputed  question  whether  the  inflamma- 
tion is  a  secondary  afiection,  or  whether  it  has  been  the  essential 
and  true  cause.  Both  views  have  some  show  of  reasoning,  and  I 
shall  therefore  consider  the  subject  at  some  length.     We  may 

*  Ancell,  on  Tuberculosis,  1852,  p.  377. 
f  Diseases  of  Children,  p.  842. 


481  DISEASES    OF    CHILDREN. 

repeatedly  witness  children  whose  general  health  fails  for  months 
together,  when  the  physical  signs  afforded  by  auscultation  and  per- 
cussion reveal  no  evidence  of  abnormal  change  in  the  pulmonary 
organs.  The  disease  may  advance  considerably  before  they  afi'ord 
any  proof  of  alteration,  and  there  may  be  extensive  tubercular 
deposit,  which  is  unsuspected. 

The  plasma  exuded  in  states  of  acute  inflammation  resembles  so 
closely  that  which  is  poured  out  in  low  forms  of  disease,  happen- 
ing to  cachectic  and  tubercular  subjects,  as  to  be  almost  identical. 
In  the  former  case,  the  essential  difference  consists  in  its  vital 
endowments,  or  capacit}^  for  higher  organization  ;  whereas  in  the 
latter  it  has  no  power  to  advance  in  this  direction,  and  the  exuda- 
tion remains  much  in  the  same  condition  as  when  it  was  first 
secreted.  The  ph3^sical  and  general  signs,  too,  between  a  case  of 
chronic  pneumonia  in  a  weakly  person  and  tubercular  infiltration, 
are  so  closely  allied  that,  notwithstanding  that  the  historj'  and 
progress  of  the  two  afi'ections  may  be  some  guide  to  diagnosis, 
they  constantly  fail  to  put  us  in  possession  of  any  conclusive  evi- 
dence. Now,  it  is  worthy  of  notice,  that  a  general  cachexia  regu- 
lates the  anatomical  character  of  all  these  exudations,  and  that  in 
the  absence  of  any  apparent  exciting  cause  there  has  still  been  a 
factor  in  operation,  which  deals  a  fatal  blow  to  the  doctrine  of 
spontaneous  origin.  The  children  of  consumptive  parents  may 
bear  characteristic  proofs  of  the  disease,  but  all  do  not  die  of 
phthisis — some  may  attain  to  a  ripe  old  age,  and  others  as  they 
reach  maturity  drop  off  one  by  one.  Every  child  bears  traces  of 
the  constitutional  diathesis  in  the  delicacy  of  form,  accelerated 
circulation,  and  general  appearance  ;  but  some  have  escaped  the 
circumstances  which  call  tuberculosis  into  action.  The  different 
functions  of  the  body  are  languidly  carried  on,  and  enough  nourish- 
ment is  appropriated  for  the  maintenance  of  life ;  or  from  some 
unforeseen  causes  (ever  ready  to  come  into  operation)  a  period 
arrives  when  an  inflammatory  affection  of  the  lungs,  or  some  other 
part,  springs  up.  Through  perverted  nutrition,  the  exudation  or 
eftusion  of  coagulable  lymph  takes  place,  and  local  disease  is  initi- 
ated. Here  is  an  argument  suggesting  the  probabilit}'  of  a  new 
power  or  agent  suddenly  altering  the  nutrition  of  an  organ  ;  but 
it  may  be  contended,  with  equal  force  of  reasoning,  that  the  exu- 
dation was  there  slumbering  and  undiscovered,  and  only  required 
the  stimulus  of  external  causes  to  rouse  it  into  action.     I  think 


ox    TUBERCULOSIS.  485 

strong  arguments  may  be  adduced  on  either  side.  It  is  evident 
that  the  earliest  signs  of  inflammation  should  be  looked  for  in 
those  persons  who  manifest  the  tubercular  cachexia  ;  and  it  will, 
I  think,  accord  with  the  experience  of  most  physicians  when  I 
add  that  there  is  a  susceptibility  to  irritation  and  congestion  of 
the  pulmonary  organs  from  trivial  causes  in  these  cases,  similar  to 
what  occurs  in  the  different  textures  of  the  body,  when  the  blood 
is  contaminated  by  the  detention  of  noxious  elements,  which  the 
impaired  or  damaged  secretory  organs  are  unable  to  elminate  from 
the  system. 

"  Catching  cold  "  is  so  constantly  assigned  as  the  starting-point 
of  active  pulmonary  disease,  that  we  cannot  escape  from  the  con- 
clusion that  it  is  no  mean  factor  in  the  development  of  tuberculosis. 
There  is  a  case  recorded  by  Dr.  Hermann  Weber*  of  a  boy,  ten 
years  of  age,  the  son  of  healthy  parents,  who  had  an  ordinary  sore 
throat,  in  August,  1871.  This  was  followed  about  the  twelfth  day 
by  pain  in  the  right  side  of  the  throat,  extending  to  the  ear,  and 
causing  deafness  ;  the  tympanic  membrane  became  yellowish  and 
prominent,  and  Dr.  Weber  suggested  that  it  should  be  perforated, 
and  if  the  advice  had  been  carried  out  it  might  have  saved  the 
child's  life.  In  ISTovember,  1871,  he  began  to  cough,  and  was  sick 
and  feverish;  the  pulse  was  139,  and  the  temperature  103°.  The 
chief  symptoms  were  headache,  sleeplessness,  constipation,  and  dry 
cough  ;  crepitant  rhonchi  were  heard,  but  no  dulness.  There  was 
deafness,  but  no  discharge  from  the  ear,  and  the  urine  was  non- 
albuminous.  There  were  two  temperature  elevations  every  day 
between  103°  and  105°,  and  two  depressions  to  between  98°  and 
100°,  and  the  pulse  varied  from  65  to  160  in  the  minute.  The 
boy  died,  November  26tli,  and  during  the  last  few  hours  of  life  the 
temperature  rose  from  101.5°  to  106°.  On  a  post-mortem  exami- 
nation gray  miliary  tubercles  were  discovered  in  the  pleura,  peri- 
cardium, liver,  and  meninges  of  the  brain.  The  right  temporal 
bone  and  internal  ear  were  normal,  but  the  tympanic  cavity  was 
filled  with  soft  caseous  matter. 

Indifferent  health  may  be  present  in  a  large  number  of  cases  for 
years,  and  the  patient  may  remain  free  from  any  actual  disease  ; 
but  when  exposure  has  led  to  cough  and  febrile  symptoms,  then 
ensue  the  usual  signs  of  bronchiiis,  accompanied  with  expectora- 
tion.    I^To  dulness  is  to  be  detected  below  the  clavicles  at  first,  or 

*  Clinical  Transactions,  vol.  viii,  1875,  p.  135. 


486  DISEASES    OF    CHILDREN. 

above  the  spine  of  the  scapula ;  but,  at  a  later  period,  this  signifi- 
cant sign  is  added  to  the  rest,  and  we  are  irresistibly  led  to  believe 
that  we  are  dealing  with  a  case  of  pulmonary  phthisis,  originating 
in  catarrh.  In  manj'  young  persons,  when  the  chest  yields  a  clear 
note  on  percussion,  and  there  is  bronchitis  affecting  the  smaller  as 
well  as  the  larger  tubes,  the  lungs  are  found  studded  with  miliary 
tubercles  after  death.  Death  has  been  so  rapid  in  many  instances 
that  the  development  of  these  granulations  must  have  preceded 
the  last  inflammatory  attack  to  have  reached  such  a  mature  stage. 
The  diminution  of  resonance  (often  not  to  be  detected)  does  not 
become  apparent  in  these  cases  till  the  bronchitis  has  existed  for 
some  considerable  length  of  time.  I  do  not  think  that  this  view 
altogether  invalidates  the  doctrine  that  the  tubercles  may  not 
have  initiated  the  bronchitis.  The  same  causes  originate  varied 
affections,  modified  by  susceptibility  and  constitution,  though  not 
following  the  same  order. 

In  the  progress  of  ordinary  phthisis,  wdiich  continues  for  years, 
each  fresh  attack  of  tubercular  deposit  is  preceded  by  bronchitis. 
It  is  of  common  occurrence  to  meet  with  children  who  have  dul- 
ness  under  one  clavicle,  harsh  or  feeble  respiration,  defective  ex- 
pansion, and  prolonged  expiration.  Such  a  patient  takes  cold  or 
gets  wet  through,  and  then  the  dulness  on  percussion  is  increased, 
and  the  inflammatorj- process  leads  to  a  farther  deposit  of  tubercle. 

When  tubercle  is  being  deposited  in  the  lung,  bronchitis  is  one 
of  the  most  common  attendant  symptoms  in  young  subjects.  If 
the  bronchitis  is  persistent,  and  does  not  yield  as  readily  as  the 
uncomplicated  aflection,it  excites  suspicion  of  tuberculosis  ;  when 
tubercle  is  disseminated  equally  through  the  pulmonary  organs, 
the  sign  of  consolidation  is  sometimes  wanting,  and  this  is  apt  to 
lead  us  astraj^.  In  a  depraved  state  of  health,  the  formation  of 
tubercle  takes  place  rapidly  or  slowly,  and  general  crepitation  may 
be  detected  throughout  the  chest ;  but  there  may  be  neither  dul- 
ness nor  prolonged  expiration.  There  is  but  little  cough,  and  if 
the  subject  is  young  the  expectoration  is  swallowed.  As  the  dis- 
ease advances  these  last  symptoms  become  more  developed,  haemop- 
tysis occurs,  the  lips  become  livid,  the  extremities  cold,  and  delirium 
may  supervene.  These  are,  of  course,  rapid  cases,  and  strictly 
bear  the  name  of  acute  phthisis.* 

Febrile  symptoms  are  significant,  and  when  the  attacks  are 

*  See  C'hiip.  XL,  On  Plithisis  Pulmonalis. 


ON   TUBERCULOSIS.  487 

severe  or  frequent  tliey  will  generally  be  found  dependent  on  the 
rapid  formation  of  tubercles.  But  persistent  feverish  symptoms 
are  sometimes  met  with  in  young  children  when  there  are  no  signs 
of  a  local  character  in  the  chest — no  cough,  no  wheezing — and  yet 
after  death  the  lungs  are  found  to  contain  tubercles.  "  I  attended 
a  little  boy,"  says  Dr.  James  Russell,  of  the  Birmingham  General 
Hospital,  "aged  six,  with  one  of  the  most  experienced  surgeons 
of  this  town.  His  illness  lasted  for  eight  weeks ;  my  attendance 
comprised  the  last  week  only.  His  sole  symptom  was  persistent 
feverish  reaction,  though  with  scarcely  any  delirium  ;  the  one 
single  symptom  of  a  local  character  was  constant  rapidity  of 
breathing.  The  child's  chest  was  searched  over  and  over  again, 
both  by  mj'  colleague  and  by  myself,  for  any  indication  of  disease, 
but  to  the  very  last  percussion  was  normal ;  not  even  a  wheeze 
could  be  discovered ;  and  there  was  entire  absence  of  cough  and 
expectoration.  Death  was  rather  sudden,  I  suspect,  from  fainting. 
On  examination,  both  lungs  were  positively  filled  with  tubercles."* 
'So  mention  is  made  of  the  temperature,  but  the  feverish  reaction 
and  rapid  breathing  were  very  significant.  If  the  half  of  one 
lung  is  obstructed  in  its  functions  by  the  rapid  development  of 
tubercles,  they  must  occasion  serious  mischief  by  diminishing  the 
power  of  the  respiratory  apparatus.  In  some  cases  where  the  pro- 
duction of  tubercles  is  rapid  and  general,  a  state  of  tubercular 
asphyxia  takes  place,  attended  with  embarrassed  breathing  border- 
ing on  suflnocation,  without  suppuration  in  the  lung  or  the  usual 
symptoms  of  phthisis. 

What  is  the  pathology  of  such  a  frequent  case  as  this  ?  A  young 
person  takes  cold  in  winter  and  is  seized  with  cough — spittingUnd 
dj'spnoea.  During  the  cold  weather  he  is  tormented  with  his  ail- 
ment, and  cannot  lose  it  till  the  warm  weather  returns.  The  pa- 
tient appears  in  good  health,  and  has  not  lost  flesh  or  strength; 
he  relishes  and  digests  his  food,  and  there  is  neither  sweating  nor 
diarrhoea.  He  is  well  in  the  summer,  but  every  winter  has  a  re- 
turn of  the  symptoms,  and  each  succeeding  attack  is  more  trouble- 
some to  shake  off  than  the  one  that  has  preceded  it.  B^'-and-by 
the  disease  does  not  subside  in  the  summer,  and  general  and  physi- 
cal signs  are  added,  which  prove  the  serious  nature  of  the  afiection  ;. 
he  now  slowly  begins  to  lose  flesh  and  strength,  and  the  expecto-- 

*  Braithwaite,  On  Fever  and  Bronchitis  as  early  signs  of  Plithisis,  vol.  Ixi,  p.  70,^ 

1865. 


488  DISEASES    OF    CHILDEEX. 

ration  becomes  thicker  and  purulent ;  cTulness  is  detected  in  one  or 
both  apices  of  the  lungs,  followed  by  softening,  and  a  fatal  termi- 
nation.    So  much  for  bronchitis  as  a  cause. 

I  am  not  sure  that  the  means  employed  to  reduce  pneumonia  in 
some  constitutions  may  not  prostrate  the  vital  powers  and  lead  to 
degeneration  of  the  effused  lymph,  which  otherwise  might  become 
organized  and  cast  off  in  the  healthy  progress  of  the  disease.  jS'o 
problem  in  medical  practice  demands  more  consideration  for  its 
solution  than  that  which  requires  us  quickly  to  determine  at  the 
bedside,  how  far  we  may  safely  venture  with  antiphlogistic  reme- 
dies in  acute  disease.  If  active  inflammation  long  assails  vital 
organs  like  the  lungs,  and  is  timidly  dealt  with,  the  effused  prod- 
ucts after  a  while  resist  absorption  and  become  irritating ;  and  if 
the  measures  emploj'ed  are  too  vigorous,  then  the  general  strength 
may  either  fail  at  once  or  decline  more  gradually.  But  a  deadly 
disorder  may  grow  out  of  the  attack.  Eare  as  it  is  for  tubercu- 
lization of  the  lung  to  succeed  pneumonia,  recent  investigations 
haveshowm  how  numerous  are  the  sources  of  blood  contamination, 
and  from  what  slight  irritation  it  may  arise,  so  that  we  cannot 
dismiss  the  dano-er  from  our  minds  where  a  laro-e  extent  of  luno; 
is  involved  in  inflammation,  even  if  no  predisposition  exists. 

Symptoms. — It  is  a  distinguishing  feature  of  tuberculosis  in 
childhood  that  several  organs  may  be  affected  at  one  and  the 
same  time, — the  lungs,  the  liver,  the  pleurfe,  the  spleen,  kidneys, 
and  peritoneum,  when  special  symptoms  common  to  disturbance 
in  an}'  of  these  organs  become  developed.  The  general  s^-mptoms, 
however,  may  be  present  for  an  indefinite  period  without  our  being 
able  to  trace  any  local  lesion,  and  w-hen  this  is  so  we  shall  presently 
see  that  the  elevation  of  temperature  is  the  only  reliable  ground 
for  diagnosis.  The  symptoms  will  vary  according  to  the  seat  of 
the  tubercular  lesion.  Among  the  earliest  I  have  noticed  is  pain 
in  the  stomach,  the  child  being  frequently  brought  under  our 
notice  b}^  his  parents  for  this  solitarj'  s^-mptom,  when  the  more 
general  and  common  features  of  the  disease,  as  loss  of  flesh,  thirst, 
and  evening  paroxysms  of  heat,  have  not  yet  indicated  its  approach. 
I  have  particularly  noticed  this  symptom  of  gastric  pain,  and  occa- 
sionally vomiting,  even  in  those  exceptional  instances  where  I  have 
had  reason  to  think  considerabe  care  has  been  bestowed  on  diet 
and  regimen.  For  weeks  together  I  have  known  this  symptom 
continue,  and  while  it  lasts  digestion  is  interfered  with,  the  chil- 


ON    TUBERCULOSIS.  489 

dren  have  a  pinched  and  exhausted  look,  and  they  lose  flesh  quickly. 
It  demands  attention  and  care,  for  it  may  be  the  evidence  of  mis- 
chief springing  up  in  the  abdomen  or  peritoneum  when  the  lungs 
are  free  from  any  infiltration  of  tubercle. 

Among  other  common  symptoms  is  a  capricious  and  irregular 
appetite,  sometimes  amounting  to  hunger,  while  at  other  times 
food  is  so  disliked  that  the  weak  stomach  can  retain  it  only  for  a 
short  time.  When  the  meal  lies  too  long  undigested  in  the  stom- 
ach it  creates  flatulence,  pain,  acid  eructations,  and  diarrhani.  The 
motions  vary  in  color  and  consistence,  sometimes  being  deficient 
in  bile  and  costive  or  loose ;  at  other  times  they  are  dark,  or  have 
a  glairy  appearance  resembling  the  white  of  an  eg^g ;  the  urine  is 
acid  and  turbid  on  standing,  throwing  down  pink  or  even  white 
lithates;  the  tongue  is  glazed  or  furred  at  the  dorsum,  or  it  is  of 
a  bright  red  at  the  tip  and  edges,  the  papilla  being  prominent. 
When  the  appetite  is  capricious  there  is  a  dislike  for  any  fatty 
kind  of  food,  thirst  is  commonly  present,  and  the  pulse  is  habitu- 
ally quick  and  weak.  If  the  local  symptoms  remain  obstinate,  a 
state  of  hectic  fever  is  established,  and  under  emaciation,  high 
temperature,  and  diaphoresis,  the  patient  gradually  dies  with  the 
local  determination  of  tubercle  to  some  special  organ,  as  the  lungs, 
brain,  or  peritoneum. 

Temperature. — Wherever  the  deposition  of  tubercle  is  taking 
place,  the  temperature  gradually  increases  in  elevation,  and  the 
destructive  changes  in  the  lung  continue.  Of  twentj-four  cases 
recorded  by  Dr.  Ringer,  in  which  tubercle  was  being  deposited,  in 
twenty-one  there  was  a  continued  elevation  of  the  temperature  of 
the  body,  and  in  these  twenty-one  cases  the  deposition  of  tubercle 
was  proved,  during  life,  by  increase  of  physical  signs,  or  after  death 
by  the  post-mortem  appearances.*  The  temperature,  according  to 
some  observers,  has  been  noticed  not  to  exceed  99°  in  some  cases 
of  acute  tuberculosis,  and  that  in  the  evening,  when  the  maximum 
temperature  is  usually  attained.  It  must  be  admitted  that  these 
cases  are  exceptional;  and  here  I  would  give  my  own  experience, 
that  the  temperature  has  been  persistently  higher  in  the  evening 
than  in  the  morning.  But  when  this  process  of  deposition  has 
ceased,  the  lung  becomes  tough  and  puckered,  and  the  cavities 
lined  with  fibrous  walls,  whilst  the  temperature  falls  to  the  normal 

*  On  the  Temperature  of  the  Body  as  a  means  of  Diagnosis  in  Phthisis  and  Tuber- 
culosis.    Walton  and  Maberly.     1865,  p.  5. 


490  DISEASES    OF    CHILDREN. 

point.  So  it  seems  evident  that  when  the  granulations  have  under- 
gone this  change,  or  have  become  quiescent  and  ceased  to  irritate, 
tuberculosis  is  curable.  These  cases  are  not  unusual.  Bronchitis, 
which  is  so  commoulv  associated  with  softening;  of  tubercle,  and 
recognized  by  rhonchus  and  moist  sounds,  is  a  symptom  to  be 
expected  and  watched  for.  Here  we  have  a  rise  of  temperature 
proportionate,  probably,  to  the  tubercular  infiltration  and  the 
bronchitis  set  up  by  it,  though  there  may  not  be  enough  to  inter- 
fere with  the  proper  aeration  of  the  blood,  or  to  excite  cough  or 
dyspncea. 

Small  deposits  of  tubercle,  when  scattered  through  a  consider- 
able portion  of  the  lung,  are  not  to  be  detected  by  physical  signs, 
and  we  may  not  suspect  such  a  condition  till  a  disease  like  pneu- 
monia or  pleurisy  sets  in.  Most  of  the  symptoms  of  failing  health 
and  delicacy  in  a  3^ouug  person  are  put  down  to  some  change  of 
constitution  in  the  absence  of  frequent  cough  and  expectoration, 
but  the  mischief  has  long  been  resident  in  the  lungs,  and  the 
inflammatory  attack  only  was  wanting  to  rouse  the  graver  evil. 
Some  years  ago  I  met  with  a  young  person  who  caught  cold,  and 
got  an  attack  of  pneumonia.  There  were  frequent  dry  cousfh, 
increased  frequency  of  respiration,  bronchial  breathing,  accelerated 
pulse,  wasting,  and  high  temperature,  but  no  expectoration  or 
moist  rales.  Percussion  was  dull  and  bronchophony  was  general 
over  the  posterior  surface  of  the  lungs.  The  patient  apparently 
recovered,  but  two  years  later  died  with  all  the  symptoms  of 
pulmonary  tuberculosis.  For  years  she  had  been  delicate,  and 
her  fiimily  feared  she  might  die. of  consumption,  but  one  medical 
man  after  another  assured  her  friends  there  was  no  deposit  of 
tubercle. 

There  are  many  cases  of  children  dying  of  tubercular  menin- 
gitis, in  whom  tubercle  is  also  met  with  in  the  lungs  and  peri- 
toneum, who  have  exhibited  no  symptoms  of  its  presence  during 
life,  and  yet  after  death  it  is  found  so  abundantly  scattered 
through  these  organs,  that  it  becomes  a  mystery  how  it  was  that 
we  did  not  discover  the  morbid  changes  that  were  going  on  by 
some  general  or  physical  signs.  Even  the  cerebral  symptoms  are 
sometimes  so  rapid  and  unexpected  that  the  source  of  mischief 
must  have  been  lying  dormant  for  some  considerable  time. 

AVhen,  moreover,  it  happens  in  tuberculosis  that  the  weight  of 
the  body  is  kept  up  (and  this  is  not  uimsual  if  the  appetite  is 


ON  TUBERCULOSIS.  491 

good,  and  there  is  no  exhausting  diarrhoea  going  on),  we  are  the 
more  driv^en  to  rely  on  a  continued  elevation  of  temperature  as 
the  only  sure  point  of  diagnosis  in  doubtful  eases.  For  a  consid- 
erable time  the  temperature  may  continue  high  and  the  weight 
of  the  body  remaiji  undiminished,  as  in  many  cases  of  ordinary 
and  advanced  phthisis  the  patients  retain  their  weight  when 
eating  well  and  taking  cod-liver  oil.  But  this  symptom  would 
not  justify  us  in  concluding  that  the  disease  was  arrested,  unless 
physical  signs  were  present  also,  and  showed  improvement.  It 
will  be  acknowledged  that,  when  patients  with  considerable  lung 
disease  are  progressing  most  satisfactorily,  they  are  liable  at  any 
moment  to  a  relapse  with  the  complications  of  profuse  expectora- 
tion or  haemoptysis.  In  these  cases,  if  we  watch  the  physical 
symptoms,  we  could  scarcely  be  unprepared  for  the  changes. 

The  temperature  in  tuberculosis  is  subject  to  so  much  variation 
that  a  large  field  of  observation  is  required  to  draw  any  practical 
conclusions  from  it,  and  cases  require  careful  and  diligent  watch- 
ing. When,  in  any  given  case  of  illness  in  a  young  person,  the 
temperature  is  daily  elevated  for  a ,  considerable  period,  and  the 
continued  fevers  can  be  excluded,  we  may  suspect  tuberculosis, 
even  if  the  general  symptoms  scarcely  point  to  the  possibility  of 
this  condition.  We  must  be  sure  that  the  thermometer  is  cor- 
rectly registered  before  it  is  placed  in  the  axilla,  and  that  the  arm 
is  kept  well  against  the  side  for  ten  minutes  or  a  quarter  of  an 
hour.*  The  temperature  is  said  to  be  so  slightly  altered  in  some 
cases  that  it  scarcely  exceeds  the  normal  standard,  but  my  expe- 
rience induces  me  to  think  that  it  never  remains  so  if  tubercle  is 
being  deposited.  Soon  the  evening  temperature  is  slightly  ele- 
vated, and  later  on,  in  some  instances,  there  is  a  rise  both  morning 
and  evening.  At  midday,  or  about  5  p.m.,  we  often  observe  a 
regular  and  well-marked  rise,  varying  according  to  the  activity  of 
the  disease. 

Dr.  Wilson  Foxf  says  that  "Lebert  found  in  22  cases  the  mean 
evening  temperature  of  acute  tuberculosis  w^as  as  follows  :  in  2  not 
exceeding  100.4^;  in  8,  including  those  last  mentioned,  not  exceed- 
ing 102.2°;  in  9,  more  than  103.4°;  in  4,  from  103.4°  to  104°;  in 

*  In  the  case  of  young  and  fractions  children,  the  thermometer  may  be  inserted 
into  the  rectum,  and  one  minute  will  be  long  enough  for  it  to  remain  there. 

t  On  the  Temperature,  Pulse,  and  Respiration  in  Phthisis  and  Acute  Tuberculiza- 
tion of  the  Lungs,  Med.-Chir.  Trans.,  vol.  Ivi,  p.  397. 


492  DISEASES   OF    CHILDEEN". 

],from  104°  to  105.5°."  Dr.  Fox  found  that  a  temperature  of 
104°  was  not  exceeded  by  62.5  per  cent,  in  acute  tuberculosis,  and 
by  S6  per  cent,  in  acute  phthisis.  Temperatures  exceeding  105°, 
with  two  exceptions  (acute  rheumatism  and  phthisis),  are  found 
exclusivel}'^  in  acute  tuberculosis.  Both  Wiinderlich  and  Lebert 
record  cases  of  hyperpyrexia!  temperature  before  death.  The 
latter  mentions  one  case  where  it  rose  to  between  107°  and  108°, 
and,  as  we  have  noticed  (p.  485),  the  temperature  reached  106° 
shortly  before  death  in  Dr.  Weber's  case. 

The  more  I  have  thought  and  pondered  over  the  fluctuations  of 
temperature  in  disease,  the  more  I  have  doubted  the  possibility  of 
constructing  any  classification  from  which  to  draw  any  accurate 
conclusions.  Diseases  "like  tuberculosis  and  phthisis,  which  are 
usually  protracted  and  tedious,  are  those  generally  selected  for 
experiment ;  but  even  these  give  such  varying  results  that  noth- 
ing absolutely  definite  or  uniform  can  be  gathered  from  them.* 
Patients  must  live  under  preciselj^  the  same  circumstances  if 
deductions  are  to  be  of  anj^  practical  value ;  the  hygienic  condi- 
tions must  be  alike,  the  age  and  constitutional  tendencies  must 
be  weighed  and  balanced  ;  the  state  of  the  lungs  must  correspond, 
the  disease  being  either  active  or  quiescent,  and  the  treatment 
must  be  the  same.  When  tubercle  is  forming,  the  temperature 
may  rise  to  106°  or  more.  Dr.  Theodore  Williams  has  recorded 
a  case  of  phthisis  in  the  "  active  third  stage,"  in  which  the  maxi- 
mum temperature  was  104.6°,  and  the  minimum  as  low  as  93. 6°. f 
There  is  often  a  rise  after  2  p.m.,  or,  as  is  frequently  the  case,  about 
5  P.M.  At  the  latter  time  it  not  unfrequently  rises  to  the  highest 
point  in  tuberculosis.  It  is  possible  that  tubercle  may  form  and 
the  disease  advance  without  any  rise  of  temperature,  which  is 
perhaps  due  to  exhaustion  and  collapse.  The  last  writer  also 
mentions  a  case  of  phthisis  in  which  active  disease  was  going  on, 
and  there  were  nightsweats  and  haemoptysis,  and  yet  the  tem- 
perature was  normal  throughout. J 

Sweating^  which  so  certainly  reduces  the  general  strength,  is  a 
common  feature  in  cases  of  phthisis,  though  it  is  not  even  a  neces- 

*  If  it  is  the  rule  to  meet  with  liigh  temperatures  in  tuberculosis,  it  should  not  be 
forgotten  that  the  lungs  may  be  studded  with  tubercles  and  the  temperature  remain 
persistently  low. 

t  On  the  Temperature  in  Phthisis  Pulmonalis,  Med.-Chir.  Trans.,  vol.  Iviii,  p.  95. 

X  Ibid.,  p.  79. 


ON   TUBERCULOSIS.  '  493 

sary  feature  here.  Where  the  temperature  remains  persistentlj'- 
high  for  some  time  and  then  begins  to  decline,  sweating  is  met 
with.  In  cases  of  nervous  exhaustion  and  general  weakness  it  is 
to  he  anticipated,  so  that,  though  it  is  not  an  invariable  rule  in 
phthisis  or  tuberculosis,  the  debility  consequent  upon  either  of 
these  last  conditions  may  produce  it  independently  of  elevation  in 
temperature.  The  sweating  that  is  due  to  a  febrile  condition  of 
the  body  is  generally  noticed  as  the  fever  declines,  and  it  thus 
becomes  a  natural  and  efficient  means  of  reducing  the  fever  with- 
out the  aid  of  drugs;  but  when  it  comes  on  from  sleep  or  exertion 
or  fasting,  it  is  due  to  exhaustion.  How  far  these  conditions  may 
coexist,  viz.,  fever  and  debility,  is  a  point  we  cannot  always  easily 
decide,  but,  as  th6  case  advances,  the  difficulty  is  cleared  up. 
Sv/eating,  therefore,  is  a  far  less  certain  indication  of  tuberculosis 
than  a  persistent  elevation  of  temperature;  though,  where  the 
latter  condition  exists,  too  much  weight  should  not  be  attached  to 
its  importance  as  a  significant  sign. 

Pulse. — The  pulse  is  another  and  more  valuable  guide  than 
sweating.  As  the  temperature  rises  the  pulse  usually  increases  in 
frequency ;  but  this  is  not  an  invariable  rule,  for  the  temperature 
may  reach  a  high  point,  as  103°  or  104°,  and  yet  the  pulse  remain 
infrequent,  and  the  respiration  quiet.  I  am  inclined  to  think  that 
when  the  pulse  and  respiration  remain  slow,  and  the  temperature 
goes  on  rising,  the  patient  is  often  in  a  perilous  position,  and  that 
more  correspondence  in  the  relations  are  preferable  for  a  hopeful 
diagnosis,  than  when  the  variance  is  so  great.  The  pulse,  there- 
fore, is  no  guide  in  the  absence  of  fever,  or  the  deposition  of 
tubercle.  Then,  too,  when  the  temperature  is  falling,  debility  and 
exhaustion  may  send  up  the  pulse,  so  that  this  is  not  an  infallible 
guide — a  nervous  or  hysterical  temperament  will  accelerate  the 
circulation,  and  this  may  deceive  some  persons  if  they  are  not 
aware  of  the  condition.  The  pulse,  therefore,  as  a  guide  to  the 
diagnosis  of  tuberculosis,  is  of  less  value  than  the  elevation  of  tem- 
perature. Dr.  Wilson  Fox  says  that  an  accelerated  pulse  is  not 
constant  in  acute  tuberculization  of  the  lungs.  He  contends  that 
it  may  be  frequently  less  than  100,  and  in  some  fatal  cases  below 
70  both  in  the  morning  and  in  the  evening.  When  the  disease  is 
progressing  or  established  the  pulse  is  quickened.  When  it  is  slow, 
and  accompanied  by  a  low  temperature,  there  is  more  chance  of 
the  disease  being  arrested  or  cured.     Of  the  relation  between  the 


494  '  DISEASES   OF   CHILDREN. 

pulse  and  the  morning  and  evening  temperatures,  wMcli  is  not 
without  scientific  interest  and  practical  value,  Dr.  Fox  found  in 
54  cases  that  the  evening  pulse  was  quicker  than  the  morning  in 
20  cases  ;  it  was  slower  than  the  morning  in  22  cases  ;  the  evening 
pulse  equal  to  the  morning  in  12  cases.  Of  the  mean  pulses,  in 
46  cases  the  evening  pulse  was  quicker  than  the  morning  in  28 
cases  ;  the  evening  pulse  was  slower  than  the  niQrning  in  12  cases  ; 
the  evening  pulse  was  equal  to  the  morning  in  6  cases. 

The  respiration  becomes  accelerated  in  proportion  to  the  severity 
of  the  disease,  and  that  in  the  evening  is  somewhat  in  excess  of  the 
morning.  Sometimes  quickness  of  breathing  is  the  chief  but  over- 
looked sj^mptom  in  acute  tuberculosis  ;  and  I  should  attach  extreme 
weight  to  such  a  symptom,  as  I  should  also  t'o  oppression  of  the 
cardiac  region  and  dyspnoea  in  rheumatic  pericarditis  before  physical 
signs  were  present.  The  respiration,  as  maj'  be  expected,  bears  a 
close  relation  to  the  quickness  and  slowness  of  the  pulse.  In 
health  thej^  correspond,  and  in  fever  as  the  circulation  is  acceler- 
ated the  respiratory  movements  become  more  frequent ;  blood  is 
transmitted  with  greater  frequency  to  the  respiratory  centre,  and 
stimulates  it  to  discharge  an  increased  amount  of  work.  In  double 
pneumonia,  when  the  blood  is  more  venous,  the  dyspnoea  and  res- 
piration become  so  increased  that  by  this  symptom  alone  we  judge 
of  the  perilous  state  of  the  patient.  When  the  tuberculosis  is  in- 
tense there  is  usually  acceleration  in  breathing,  and  both  in  the 
morning  and  in  the  evening  the  respirations  are  above  30  in  the 
minute.  In  54  cases  of  the  quickest  pulse,  the  evening  respiration 
was  quicker  than  the  morning  in  25  cases  ;  the  evening  respiration 
slower  than  the  morning  in  23  cases ;  the  evening  respiration  was 
equal  to  the  morning  in  6  cases.  In  54  cases  of  the  slowest  pulse 
the  evening  respiration  was  quicker  than  the  morning  in  24  cases  ; 
the  evening  respiration  slower  than  the  morning  in  17  cases;  the 
evening  respiration  equal  to  the  morning  in  13  cases.  Of  the  mean 
respiration  in  46  cases  the  evening  respiration  was  quicker  than 
the  morning  in  20  cases  ;  the  evening  respiration  slower  than  the 
morning  in  20  cases  ;  the  evening  respiration  equal  to  the  morning 
in  6  cases. 

But  between  the  rate  of  the  pulse  and  the  temperature,  as  I 
have  previously  stated,  there  is  no  necessarj^  relation.  The  tem- 
perature may  be  high,  and  the  pulse  slow,  or  vke  versa.  We  may 
have  a  morning  pulse  of  140  and  the  temperature  97° ;  the  evening 


ON   TUBERCULOSIS.  '  495 

pulse  ma}'  be  130  and  the  temperature  95°  or  96°  (Wilson  Fox). 
We  must  infer  tliat  the  variation  in  temperature  may  he  accom- 
panied with  a  pulse  of  the  same  frequency ;  those  cases  which  are 
distinguished  by  a  rapid  pulse  are  commonly  those  where  the 
temperature  is  highest,  and  low  pulses  are  generaly  met  with 
where  the  temperatures  are  lo\v.  These  conclusions  of  Dr.  Fox 
accor<l  with  my  experience  of  some  other  pyrexial  states.  Quick 
breathing  may  be  associated  with  a  slow  pulse,  and  in  exceptional 
cases  slow  breathing  with  a  quick  pulse.  In  one  case  of  acute 
tuberculosis,  the  quickest  pulse  was  136,  and  the  respirations  28  ; 
the  slowest  pulse  was  88,  and  the  respirations  32.  Some  condition 
of  the  nervous  centres  due  to  hysteria  or  exhaustion  may  explain 
this. 

The  relation  of  the  respiration  to  the  pulse  is  more  definite  than 
it  is  to  the  temperature ;  the  slow  pulse  is  usually  accompanied  by 
retardation  of  the  respiration,  whether  it  be  morning  or  evening  ; 
but  the  pulse  may  be  slow  whilst  the  respiration  is  rapid.  The 
pulse  is  more  influenced  by  the  temperature  than  the  breathing ; 
a  slow  pulse  and  rapid  breathing  may  coexist  with  low  tempera- 
tures, but  a  quick  pulse  and  rapid  breathing  may  also  be  associated 
with  low  teaiperature.  AYhen  the  pulse  and  respiration  are  both 
low  the  temperature  is  generally  normal,  or  nearly  so.  Pyrexia 
may  exist  with  little  acceleration  of  either;  or  the  temperature 
may  be  high  and  the  pulse  quick,  whilst  the  respiration  is  scarcely 
accelerated.  This  applies  to  some  other  febrile  states  besides 
tuberculosis. 

According  to  Dr.  E,  Smith  and  Dr.  Fox,  rapid  pulses  with  slow 
breathing  are  not  observed  in  the  early  stages  of  phthisis.  For 
many  of  the  foregoing  calculations  concerning  the  relations  of  the 
temperature,  pulse,  and  respiration  in  tuberculosis  I  am  indebted 
to  the  perusal  of  Dr.  Fox's  paper  on  this  subject,  who  has  col- 
lected a  large  number  of  facts  from  his  experience  and  that  of 
others.* 

The  two  following  cases  are  not  without  interest. 

Case  I. — Jane  C ,  tet.  6|  years,  first  came  under  my  care  at 

the  Samaritan  Hospital  on  October  24th,  1874.  She  was  an  intel- 
ligent child,  with  fair  hair  and  gray  eyes,  and  had  grown  beyond 
her  strength.  During  the  winter  of  1873  she  had  had  an  attack 
of  croup,  and  had  been  ailing  ever  since.     Her  father  and  mother 

*  Med.-Chir.  Trans.,  vol.  Ivi,  1873. 


496  DISEASES   OF   CHILDEEX. 

were  health}^,  but  a  younger  brother  was  the  subject  of  rickets. 
She  was  too  weak  to  take  au}^  exertiou,  and  in  the  evening  was 
feverish  and  hot,  with  a  bright  circumscribed  flush  on  the  left 
cheek.  It  was  seklom  observed  on  the  right  cheek.  The  chief 
symptoms  complained  of  were  pain  in  the  stomach  and  constant 
sickness,  so  that  she  could  retain  nothing  that  slie  swallowed. 
She  had  a  short,  frequent,  and  troublesome  cough,  and  expecto- 
rated a  little  thin  phlegm  ;  she  complained  of  thirst  and  head- 
ache, and  the  tongue  was  covered  with  a  thick  white  fur ;  latterly, 
she  had  become  irritable  and  tidgety,  and  it  was  difficult  to  amuse 
or  please  her.  There  was  some  obscure  dulness  under  the  left 
claivicle,  but  no  harshness  of  breathing  or  moist  sounds ;  the 
cardiac  sounds  were  very  distinct  under  both  clavicles.  The  tem- 
perature was  101.5°,  pulse  160,  respiration  -±0.  I  ordered  the 
child  to  be  kept  in  the  prone  position  until  the  sickness  was 
relieved,  and  to  be  fed  frequently  with  a  tablespoonful  of  milk 
and  lime-water.  In  the  shape  of  medicine,  citrate  of  potash  was 
given  in  efltervescence  with  hydrocj'anic  acid.  She  was  to  be 
sponged  with  tepid  water  in  the  evening,  and  if  free  from  pain,  to 
liave  a  grain  and  a  half  of  quinine  in  a  powder  at  bedtime  before 
the  paroxysms  were  expected. 

27th. — The  child  was  better,  but  the  flushing  had  continued 
regularly  morning  and  evening;  an}'  fatigue  or  excitement  brought 
it  on.  The  sickness  and  pain  in  the  stomach  were  abated,  she  slept 
quietlj^  at  night,  and  made  no  complaint  of  lieadache  ;  the  tongue 
was  cleaning  at  the  tip  and  edges ;  pulse  96,  temperature  99°.  As 
the  bowels  were  inclined  to  be  costive,  and  the  motions  green,  I 
prescribed  a  powder  at  bedtime,  consisting  of  gray  powder,  bicar- 
bonate of  soda,  and  powdered  rhubarb,  of  each  two  grains. 

il^ovember  10th. — She  was  much  better,  having  had  flushing  of 
the  face  onl}-  twice  the  previous  week  on  the  same  daj- ;  the  sick- 
ness was  completely  arrested,  and  the  bowels  acted  regularly  every 
morning  ;  the  tongue  was  clean,  and  she  was  bright  and  animated; 
pulse  92  ;  temperature  99.1°  ;  respirations  24;  urine  clear.  T\"lieu 
the  fever  was  ofi"  her  she  was  to  take  the  quinine  powder  three 
times  a  day.  Since  last  visit  she  had  taken  a  pint  of  milk  dailj-, 
besides  beef  tea  and  mutton  broth. 

24th. — She  had  much  improved,  her  cheeks  having  filled  out, 
and  her  appetite  amounting  to  hunger.  The  temperature  was 
only  98°,  the  pulse  was  140,  and  this  probably  from  nervousness, 


ON   TUBERCULOSIS.  497 

as  an  attempt  at  examination  was  enough  to  cause  flushing.  She 
had  flushing  of  the  left  cheek  from  overexcitement  at  play  ;  it 
had  been  noticed  on  both  cheeks,  but  generally  on  the  left — never 
on  the  right  cheek  alone.  She  spat  up  a  good  deal  of  phlegm, 
and  often  had  the  feeling  of  wishing  to  clear  her  throat ;  the 
bowels  were  quite  regular.  Since  her  illness  began  she  was  gen- 
erally restless  in  her  sleep,  and  at  these  times  was  always  flushed ; 
the  abdomen  was  increasing  in  size,  and  her  clothes  came  together 
round  the  waist  with  difliculty.  The  mother  noticed  this  swell- 
ing for  the  first  time  a  week  before.  The  region  of  the  liver  was 
smooth,  but  slightly  projected  below  the  ribs,  and  the  bell}'  gen- 
erally was  tumid  and  protuberant,  though  free  from  pain  and 
tenderness.  She  was  ordered  a  teaspoonful  of  cod-liver  oil  twice 
a  day,  and  as  much  nutriment  as  she  could  digest  comfortably. 

On  December  8th  the  report  states  that  the  bowels  had  become 
very  loose  ;  the  motions  being  dark  and  ragged-looking;  she  com- 
plained of  pain  in  her  eyes,  and  there  was  headache ;  since  the 
diarrhoea  began  there  had  been  more  flushing,  which  kept  to  the 
left  cheek  ;  the  abdomen  still  increased  in  size.  There  was  more 
cough,  and  some  dulness  below  the  spine  of  the  left  scapula,  with 
mucoQS  rhonchus.  The  mother  refused  the  child  to  be  admitted 
as  an  in-patient,  and  I  did  not  see  her  again  till  November  6th, 
1875,  when,  on  calling  at  her  house,  I  ascertained  the  following 
facts:  After  her  last  visit  she  remained  ill  for  about  a  month, 
and  then  gradually  regained  her  flesh  and  strength,  and  her  body 
returned  to  its  normal  size.  The  medicine  was  continued  regularly 
during  this  time.  The  chest  now  expanded  well,  but  the  percus- 
sion-note did  not  appear  to  be  quite  so  clear  on  the  left  side  as  on 
the  right,  and  there  was  dulness  in  the  suprascapular  space  of  the 
same  side,  but  no  moist  sounds  anj^where.  There  was  no  enlarge- 
ment of  the  liver  or  spleen,  and  the  belly  was  soft  and  natural. 
Allowing  for  some  excitement  at  my  unexpected  visit,  I  found  the 
pulse  did  not  exceed  84,  respirations  24,  temperature  normal.  The 
child  was  in  every  respect  healthy,  and  went  to  school  regularly. 
I  see  no  reason  to  deny  the  possibility  of  a  deposit  of  tubercle  in 
this  case,  and  the  fall  of  temperature  indicates  its  arrest,  if  not  its 
cure. 

Case  IL — P.  E ,  set.  12,  was  first  brought  to  me  on  the  19th 

of  April,  1875;  he  w^as  the  son  of  healthy  parents  residing  in  an 
elevated  district  in  the  neighborhood  of  London,  and  had  five 

32 


498  DISEASES    OF    CHILDREN. 

brothers  and  one  sister.  The  eldest  brother  died  at  fourteen  years 
of  age  of  heart  disease,  apparently  unconnected  with  rheumatism. 
He  had  always  experienced  fair  health  till  six  weeks  since,  when 
he  took  cold,  and  had  feverish  symptoms  at  his  school  in  Stafford- 
shire, where  the  atmosphere  was  damp  and  humid.  His  illness 
was  thought  to  be  whooping-cough,  but  this  was  doubtful,  as  no 
medical  man  was  consulted,  and  after  his  return  home  his  parents 
never  heard  him  whoop.  His  second  brother,  who  went  to  the 
same  school,  was  lately  seized  with  rheumatic  fever,  and  died  there. 
He  had  lost  much  flesh,  and  was  very  thin,  his  clothes  hanging 
loosely  on  him.  He  was  a  slender  and  delicate  lad,  with  downcast 
eyes,  and  a  sad,  wearied  expression  ;  the  veins  were  very  prominent 
and  distended  over  the  front  part  of  the  chest,  and  the  spine  was 
much  curved  from  weakness,  the  lower  angle  of  the  right  scapula 
being  within  an  inch  of  the  spine  ;  the  left  was  three  inches  from 
it.  Phthisis  was  not  hereditary,  and  no  member  of  the  family  on 
either  side  appeared  to  have  suffered  from  it.  The  symptoms  com- 
plained of  were  great  languor  and  prostration  of  the  strength  ;  he 
had  little  inclination  to  enter  into  any  amusement  with  his  brothers, 
and  if  he  did  he  was  soon  fatigued  and  glad  to  lie  down.  He  had 
a  short,  frequent,  hoarse  cough,  and  spat  up  a  little  light  tenacious 
phlegm  in  the  daj^time,  but  more  particularly  in  the  morning  on 
waking.  Towards  evening  he  got  flushed,  and  complained  of 
headache  and  thirst ;  his  mother  noticed  that  he  was  restless  in 
his  sleep,  and  that  the  skin  was  hot  and  not  sweating.  On  exami- 
nation of  his  chest  the  expansion  was  good  and  equal  under  both 
clavicles,  though,  in  consequence  of  his  having  lost  so  much  flesh, 
the  depressions  above  and  below  the  clavicles  were  very  marked, 
and  the  shoulders  rounded  and  bent  forward  ;  the  percussion-note 
was  resonant,  and  the  vocal  vibration  greater  than  usual ;  but  this 
was  explicable  on  the  ground  that  the  thoracic  walls  were  very 
thin,  and  the  intercostal  spaces  everywhere  depressed. 

A  similar  reason  may  explain  the  loud  and  rather  harsh  char- 
acter of  the  respiration  under  both  clavicles,  but  there  were  no 
moist  sounds.  On  percussing  the  back  the  dulness  was  greater  in 
the  supra-spinous  fossa  on  the  left  side  than  on  the  right;  but  in 
the  absence  of  submucous  or  sonorous  rhonchus,  the  result  of  this 
physical  examination  did  not  enable  me  to  pronounce  the  patient 
tubercular  when  I  was  pressed  for  an  opinion.  I  thought  he  was, 
and  that  in  the  course  of  a  short  time  I  should  detect  unmistaka- 


ON   TUBERCULOSIS.  499 

ble  evidence  of  such  pulmonary  changes  that  all  doubt  would  be 
set  at  rest.  The  skin  was  dry  and  harsh,  the  temperature  102°  ; 
the  pulse  136  ;  the  respiration  quiet ;  bowels  costive ;  urine  clear 
and  non-albuminous  ;  the  tongue  presented  a  whitish  coating,  and 
the  appetite  for  food  was  imperfect,  which  in  genuine  tuberculosis 
is  sometimes  craving  and  voracious.  I  ordered  him  a  diet  of  beef 
tea,  milk  and  eggs,  and  he  was  to  have  cocoa  instead  of  tea.  In 
the  shape  of  medicine  two  grains  of  quinine  were  prescribed,  morn- 
ing and  evening,  and  a  syrup  composed  of  squill,  senna,  and  poppy, 
to  soothe  his  cough  and  keep  the  bowels  open.     (Form.  64-74.) 

May  loth. — He  looked  marvellously  better,  being  fuller  in  the 
face  and  more  animated  ;  he  had  coughed  less,  and  was  never 
flushed  in  the  evening ;  his  appetite  was  greatly  improved,  and  he 
rested  well  at  night ;  pulse  112  ;  respirations  24  ;  temperature  98°. 
For  three  days  he  had  complained  of  pain  in  the  right  side,  below 
the  nipple,  which  was  increased  on  coughing  or  taking  a  deep  in- 
spiration ;  but  as  auscultation  revealed  nothing  abnormal,  the  pain 
was  probably  neuralgic  or  muscular.  The  chest-sounds  were  the 
same  as  at  the  last  report,  but  there  was  some  laryngeal  irritation 
and  hoarseness.  He  was  ordered  to  apply  a  warm  poultice  to  the 
side  at  night,  and  to  use  a  sponge-bath  with  Tidman's  sea  salt 
every  morning.  A  mixture  containing  hypophosphite  of  lime, 
quinine,  strychnia,  and  tincture  of  perchloride  of  iron  was  substi- 
tuted for  the  simple  quinine  mixture.*  This  is  an  excellent  com- 
bination in  cases  of  angsmia  and  nervous  exhaustion,  and  the  slow 
blood-change  which  occurs  in  the  diatheses  of  struma,  syphilis,  and 
tubercle.f 

June  9th. — The  laryngeal  irritation  had  not  lessened,  and  the 
cough  was  hacking  and  troublesome  in  the  morning,  but  unat- 
tended with  expectoration ;  there  was  no  sweating,  and  he  slept 
well.     ISTearly  three  months  later  (at  the  end  of  August),  after 

*  Formula  73 : 

R.  Calcis  hypopliosphitis, Qij 

Tinct.  ferri  perchl., giss. 

Quinia?  sulph., ^      .         .        .         ,    gr.  vj 

Liquor,  strychnioe, ^ss. 

Synipi, Ij 

Aquam  ad §vj. — M. 

A  tablespoonful  three  times  a  day. 
f  See  a  paper  by  the  author  On  the  Hypopliosphites  of  Iron,  Quinine,  and  Strychnia, 
in  cases  of  General  Debility  and  Nervous  Exhaustion,  Clin.  Trans.,  1870,  vol.  iii,  p.  1. 


500  DISEASES   OF   CHLLDREX. 

gaining  flesh  and  going  on  remarkably  well,  lie  became  faint  and 
languid  and  lost  his  appetite  from  indiscretion  in  diet.  He  was 
irritable  and  fretful,  and  nothing,  went  right  with  him,  which  was 
attributable  in  a  great  measure  to  over  fatigue  and  excitement  in 
the  hot  weather.  His  voice  was  now  clear,  and  he  did  not  suffer 
from  cough  or  laryngeal  irritation.  The  chest-sounds  were  normal. 
He  derived  the  greatest  benefit  from  the  hypophosphites,  and  a 
month  later  went  to  Brighton  apparently  well. 

I  might  relate  other  eases-  of  a  mixed  and  puzzling  character, 
allied  to  genuine  tuberculosis  in  many  of  the  local  and  vital  symp- 
toms. If  the  lungs  and  other  organs  appear  to  be  free  from  the 
deposit  of  tubercle  at  the  tioie  a  patient  comes  under  observation 
we  may  pronounce  the  illness  as  simple  and  uncomplicated,  and 
give  a  favorable  opinion,  because  recovery,  so  far  as  I  have  been 
able  to  trace  the  progress  of  the  disorder,  has  sometimes  followed 
the  continuance  of  a  class  of  symptoms  which  have  borne  the 
closest  connection  with  what  appeared  to  be  at  one  time  an  irre- 
mediably hopeless  condition. 

AVe  will  consider  the  treatment  in  the  next  chapter. 


CHAPTER   XL. 

PHTHISIS   PULMONALIS    OR    PULMONARY   CONSUMPTION. 

Definition  of  the  term — Nature  of  the  disease — Analysis  of  the  blood  in  phthisis — Varieties 
of  phthisis.  Acute  Phthisis  or  Galloping  Consumption  (Acute  Tubercu- 
losis)— Acute  Pneumonic  Phthisis — Bronchial  or  Catarrhal  Phthisis 
(Caseous  or  Scrofulous  Pneumonia) — Chronic  Phthisis  (Chronic  Tuber- 
culosis— Tubercular  Phthisis) — Fibroid  Phthisis  (Cirrhosis  of  the 
Lung).  Symptoms:  Constitutional — State  of  pulse — Cough — Hcemoptysis — Diar- 
rhoea— Physical  signs  of  the  different  stages — Duration  of  the  disease — Complications. 
Causes  :  Predisposing  and.  exciting — Inflammatory  origin  of — The  scrofulous  diathesis 
— Hereditary  tendency — Ancemia — Exhausting  illness.  Diagnosis  of  Acute 
Phthisis  from  Typhoid  Fever — Treatment  op  Tuberculosis  :  General 
managemait — Effect  of  quinine  and  purgatives — Cold  sponging — Cod-liver  oil — Change 
of  air — Sea  bathing.  Treatment  of  Phthisis  to  be  regulated  according  to  the 
stage  of  the  disease — Early  or  incipient  phthisis — Attention  to  the  digestive  functions — 
Avoidance  of  cold — Warm  clothing  and  attention  to  the  general  health — Counter-irrita- 
tion— Seaside  residence — Action  of  belladonna  in  controlling  nightswedts  and  diar- 
rhcea — Sulphate  of  atropia —  Vinegar  and  capsicum  as  a  local  application — Manage- 
ment of  the  second  or  confirmed  stage  of  the  disease — To  encourage  expectoration,  when 


PULMONARY   CONSUMPTION.  501 

it  is  copious  and  oppresses  the  patient,  by  emetics  of  sulphate  of  zinc  and  ipecacuanha — '' 
Treatment  of  cough — IJcemoptysis  and  diarrhoea — Management  of  the  febrile  paroxysms 
— Hypophosphltes  of  lime  and  soda — Calumba — Bark — Preparations  of  iron — Quinine 
— Strychnia — Cod-liver  oil — Phosphoric  acid. 

It  may  be  well  now  to  consider  the  disease  called  phthisis  from 
a  special  or  clinical  point  of  view.  Already  I  have  referred  to  it 
with  regard  to  its  relation  to  tuberculosis.  ISTow  there  are  forms 
of  phthisis  not  clearly  tubercular,  but  as  tubercle  bears  so  close  a 
relation  to  this  subject,  I  must  again  repeat  much  of  what  I  have 
said  in  the  chapter  on  tuberculosis,  just  as  in  that  chapter  I  was 
obliged  to  anticipate  much  that  will  be  said  on  phthisis  here. 

The  usual  acceptation  of  the  term  pulmonary  phthisis  means 
wasting  away.  It  is  a  constitutional  rather  than  a  local  affection, 
associated  with  malnutrition  and  a  depraved  state  of  the  blood, 
leading  to  destructive  disease  of  the  lung.  In  England  it  is  both 
common  and  fatal,  on  account  of  the  variable  temperature  of  this 
country.  It  spares  neither  sex  nor  age  ;  but  the  young  are  its 
special  victims.*  As  we  have  said  before,  when  speaking  of 
tuberculosis,  phthisis,  which  in  its  commonest  types  is  allied  to 
that  disease,  is  often  associated  with  a  certain  delicate  physical 
beauty,  and  with  high  mental  qualities.  The  gradual  sinking 
and  death  of  a  typically  phthisical  subject  has  a  painful,  yet  pic- 
turesque aspect,  which  has  not  escaped  the  notice  of  artists, 
poets,  and  writers  of  works  of  fiction.  Those  who  are  fair  and 
beautiful,  refined  and  accomplished,  succumb  rapidly  or  gradually 
to  its  ravages. 

The  leading  constitutional  symptoms  which  denote  its  presence 
are  a  gradual  decline  in  the  general  health,  and  a  persistent  and 
harassing  cough,  with  little  or  no  expectoration  at  first,  accel- 
erated breathing  and  pulse,  febrile  paroxysms,  nightsweats,  dis- 
turbed sleep,  emaciation,  diarrhoea,  and  occasionally  sudden  death. 
The  physical  signs  are  those  of  pulmonary  congestion,  followed 
by  consolidation,  and  eventually  by  the  breaking  down  of  the  lung 
itself. 

The  peculiarities  which  distinguish  the  deposition  of  tubercle  in 
early  life  cannot  be  too  strongly  insisted  on  and  understood,  for 
they  are  strikingly  different  to  what  we  observe  in  later  years.    In 

*  Of  584  cases  noted  by  Dr.  Austin  Flint,  only  one  case  occurred  under  ten,  and  one- 
half  the  cases  occurred  between  twenty  and  thirty.  Dr.  Dobell's  Kepofts  on  Diseases 
of  the  Chest,  vol.  ii,  1876,  p.  19. 


502  DISEASES    OF    CHILDREN. 

children  there  is  a  tendency  to  the  diiiusion  of  tubercle  in  the 
chief  internal  organs — as  the  brain,  the  lungs,  liver,  spleen,  kidneys, 
bronchial  and  mesenteric  glands,  whereas  in  adults  the  pulmonary 
organs  are  remarkably  prone  to  suffer.  The  disease  may  continue 
in  one  lung  for  years,  and  ultimately  cause  death  without  spread- 
ing to  the  other.  Cavities  are  not  common  in  the  lungs  of  children, 
though  I  suspect  that  in  catarrhal  phthisis  they  are  of  more  fre- 
quent occurrence  than  is  generally  supposed.  Certainly  the  cavi- 
ties are  smaller,  and  they  are  sometimes  numerous.  This  general 
diffusion  of  tubercle  in  children  lends  considerable  support  to  Dr. 
"VTilson  Fox's  view,  that  pulmonary  tubercle  is  a  primary  growth, 
and  the  changes  that  subsequently  ensue  are  owing  to  inflamma- 
tion.* This  of  course  involves  the  question  of  hereditary  liability, 
and  a  state  of  the  blood  and  tissues  favorable  to  the  tubercular 
dyscrasia.  Dr.  Andrew  Clark  notes  a  different  view,  as  the  fol- 
lowing extract  shows : 

"  The  generic  term  (phthisis)  comprehends  all  progressive  con- 
solidations and  circumscribed  suppurative  disintegrations  of  the 
lungs;  the  specific  term  should  indicate  by  a  distinct  adjunct  the 
different  states  concurring  to  this  end.  For  surely  if  the  progres- 
sive consolidation  and  suppurative  destruction  of  lung  constituting 
phthisis  be  determined  in  one  instance  by  tubercles,  in  another  by 
pneumonic  exudations,  in  a  third  by  scrofulous  growths,  and  in  a 
fourth  by  fibrous  invasions,  and  if  these  things  be  in  any  sense 
different  from  one  another,  common  sense  demands  that  their  dif- 
ferences should  be  permanently  recorded  by  distinctive  designation. 
Hence  it  is  both  convenient  and  correct  to  speak  of  tubercular, 
scrofulous,  pneumonic,  fibrous,  and  bronchial  phthisis. "f 

"We  have  now  to  inquire  in  what  the  disease  consists,  how  it 
orio-inates,  and  what  is  its  true  pathology? 

These  are  questions  to  be  answered  before  we  can  proceed  to  dis- 
cuss its  causes  and  its  treatment.  In  ascribing  it  to  a  defect  or 
disturbance  in  the  functions  of  any  particular  organ  or  tissue,  we 
have  still  to  inquire  in  what  the  morbid  action  consists.  Is  it  not 
due  to  some  primary  blood  change,  which  alters  the  nutrition  of 
the  body,  and  deranges  the  circulation,  thus  leading  to  exudation 
of  materials  of  a  low  standard,  incapable  of  absorption  and  irritat- 
ing to  the  organs  in  which  they  are  deposited,  and  thus  by  causing , 

*  Trans.  Path.  Soc.,  1873. 

t  Clin.  Trans.,  Case  of  Fibroid  Phthisis,  bv  Andrew  Clark,  M.D.,  1868,  p.  187. 


PULMONARY   CONSUMPTION.  503 

the  production  in  them  of  fresh  growths,  involves  them  in  destruc- 
tion and  decay.  This  seems  a  reasonable  hypothesis,  if,  as  I  have 
pointed  out  in  the  previous  chapter,  the  subcutaneous  injection  of 
inflammatory  products,  or  tubercle  itself,  can  originate  the  disorder 
in  some  of  the  lower  animals.* 

There  is  cell  growth  of  imperfect  formation  with  a  great  ten- 
dency to  die,  the  more  rapidly  the  cells  are  formed  the  less  vitality 
they  have.  Healthy  blood  determines  a  healthy  performance  of 
all  the  organic  functions,  digestion,  nutrition,  circulation,  secretion, 
and  excretion ;  but  when  it  is  diseased  or  altered  from  tliat  of 
health,  then  indisposition  in  some  shape  or  form  arises.  Some 
function  departs  from  its  normal  condition ;  and  where  the  tuber- 
cular habit  is  present  a  morbid  change  ensues,  which  leads  to  the 
formation  of  tubercle,  just  as  some  other  habit  of  body  may  de- 
velop another  organic  disease. 

We  can  no  more  conjecture  what  determines  this  particular 
change  than  why  children  of  the  same  family  differ  in  physical 
form  and  mental  capacity.  It  is  an  inscrutable  law  beyond  the 
limits  of  our  understanding. 

Acute  Phthisis  (acute  tuberculosis). — I  have  briefly  alluded  to 
this  in  the  last  chapter,  and  quoted  a  case  by  Dr.  James  Russell,  of 
Birmingham,  in  which  the  lungs  were  studded  with  tubercles,  and 
yet  the  patient  had  no  physical  symptoms  before  death  beyond 
rapid  breathing.  It  was  evidently  a  case  of  acute  phthisis,  such 
as  we  sometimes  see  in  young  subjects  following  cold,  and  in  whom 
there  is  a  constitutional  liability  to  the  disease.  The  disease  is  so 
rapid  and  violent  in  its  character,  that  there  is  no  time  for  the 
action  of  remedies,  and  it  runs  its  fatal  course  in  a  few  weeks. 
The  absence  of  physical  signs  when  a  few  tubercles  are  deposited 
through  the  lungs  is  common  enough,  and  we  often  see  this  veri- 
fied in  the  post-mortem  room.  In  such  cases,  there  is  frequently 
no  dulness  on  percussion,  and  no  alteration  in  the  breath-sounds. 
"When  miliar}'-  tubercles  are  thickly  deposited  through  the  lungs, 
there  w^ill  be  found  general  bronchitis,  announced  by  rhonchus  and 
sibilus,  the  chest  may  or  may  not  be  dull  in  places,  and  the  pulse 
and  respirations  are  accelerated.  The  w^eaknessis  very  great,  and 
the  wasting  of  flesh  general.  In  the  autumn  of  1879,  I  was  re- 
quested by  a  neighboring  practitioner  to  see  with  him  a  boy  ten 
years  of  age,  who  was  dying  from  pulmonary  disease.     Several 

*  See  Chap.  XXXTX,  On  Tuberculosis. 


504  DISEASES   OF   CHILDEEIST. 

members  of  the  family  had  died  of  consumption.  He  had  been 
only  ailing  a  month  with  rheumatic  pains  in  his  joints,  and  had 
had  no  cough  till  within  a  few  days  of  my  visit.  We  found  him 
sitting  up  in  bed  perfectly  collected  and  intelligent,  but  breathing 
rapidly  ;  the  livid  lips,  the  pallid  face,  the  coldness  of  the  hands, 
and  the  failing  pulse,  told  of  his  approaching  dissolution.  The 
chest  was  resonant  on  percussion  both  in  front  and  behind,  but 
universal  rales  were  heard  throughout  all  diameters  of  the  bron- 
chial tubes,  which  were  enormously  loaded  with  mucus.  Below 
the  spine  of  the  left  scapula,  the  lung  was  evidently  breaking  down, 
judging  from  the  cracked-pot  sound  on  percussion,  and  the  bron- 
chial breathing.  I  suspect  that  the  other  portions  of  the  lungs 
were  filled  with  gray  granulations,  and  some  of  them  were  passing 
into  caseous  change.  The  patient  gradually  became  worse,  and 
died  in  about  thirty-six  hours  after  my  visit,  l^o  post-mortem 
examination  was  permitted.  "  They  (gray  granulations)  break  out 
simultaneously,  like  the  eruption  of  an  exanthem,  and  by  their 
numbers  and  bulk  induce  such  an  amount  of  obstruction  and  con- 
gestion of  the  lungs,  as  to  destroy  life  before  there  is  time  for 
any  considerable  degeneration  or  softening  to  take  place.  This 
acute  tuberculosis  is  the  worst  and  most  surely  fatal  form  of  con- 
sumption."* 

Another  form  of  acute  phthisis  is  that  which  commences  with 
inflammation  in  one  or  both  lungs,  loss  of  appetite,  dry  lips,  red 
tongue,  thirst,  cough,  and  expectoration.  There  may  be  haemop- 
tysis. There  is  usually  high  fever,  the  temperature  reaching  105° 
in  some  cases  in  the  evening,  quick  pulse  and  accelerated  respira- 
tion, followed  by  chilliness,  and  sweats  at  night.  The  physical 
signs,  if  limited  to  one  lung,  indicate  the  stage  at  which  the  dis- 
ease has  arrived,  from  duluess  on  percussion  arising  from  consoli- 
dation to  the  cracked-pot  sound,  and  tubular  or  bronchial  breathing 
with  coarse  crepitation.  Death  may  take  place  in  a  few  weeks. 
After  death  the  lungs  are  found  consolidated  and  hepatized  from 
inflanmiatory  deposit,  and  in  places  the  yellow  matter  is  breaking 
down  into  cavities.  It  is  this  form  of  disease  which  has  received 
the  name  of  galloping  consumption.  "  To  my  mind,  what  seems 
certain  in  this  form  is  that   scrofulous  imflammation,  scattered 

*  Pulmonary  Consumption,  by  Drs.  C.  J.  B.  Williams  and  C.  Theodore  Williams, 
1871,  p.  2. 


PULMONAEY   CONSUMPTION.  505 

broadly  tlirongh  the  pulmonary  substance,  causes  its  rapid  and 
extensive  disorganization."* 

In  treating  of  the  pathology  of  bronchopneumonia,  I  mentioned 
that  it  sometimes  ended  in  tuberculosis  and  caseous  change.  This 
is  really  one  of  the  forms  of  phthisis  called  "Catarrhal  Phthisis," 
the  result  of  inflammation.  It  is  therefore  implied  that  phthisis 
is  sometimes  due  to  inflammation  which  has  clogged  up  the  air- 
vesicles,  and  at  others  to  degenerative  changes,  to  adenoid  or 
lymphatic,  throughout  the  pulmonary  tissue,  in  which  the  bronchi 
have  no  share  in  the  morbid  process.  That  form  of  consumption 
in  which  miliary  tubercle  is  scattered  through  the  lung  without 
breaking  down  of  its  tissue  into  destruction  and  cavities,  I  have 
spoken  of  in  the  last  chapter. 

Catarrhal  'phthisis  is  a  form  of  phthisis  prone  to  follow  the 
bronchopneumonia  of  an  exanthematous  affection,  especially 
measles.  It  is  essentially  a  pneumonic  disease,  and  does  not  owe 
its  origin  to  tubercle.  Extensive  caseous  changes  may  take  place 
in  the  consolidation  resulting  from  bronchopneumonia,  and  the 
child  may  be  in  fair  health,  till  an  acute  febrile  disorder  rouses 
the  exudation  into  activity,  fresh  centres  appear,  and  the  lung 
softens  and  breaks  down  into  cavities.  Where  cavities  exist  after 
death,  fibrous  tissue  sometimes  circumscribes  them,  and  binds  the 
lung. to  the  chest-wall.  I  have  known  one  lung  perfectly  solid 
from  caseous  consolidation  in  a  child  five  years  of  age,  who  had 
scarcely  any  cough,  and  no  febrile  disturbance  till  measles  super- 
vened, and  then  the  lurking  mischief  was  at  once  excited,  and 
death  took  place  a  few  days  after  the  disappearance  of  the  rash. 
After  death  there  were  two  cavities  in  the  left  lung  which  showed 
recent  formation.  There  was  no  healthy  lung-tissue.  The  right 
lung  presented  no  trace  of  disease,  but  tubercles  were  found  in  the 
liver  and  spleen,  and  there  were  also  enlarged  bronchial  and  mes- 
enteric glands.  "  This  condition  is  the  yellow  tubercular  infiltra- 
tion of  Laennec,  the  scrofulous  pneumonia,  caseous  pneumonia,  or 
tubercular  pneumonia  of  diflerent  modern  writers."t 

When  phthisis  is  chronic,  and  is  seen  in  connection  with  tubercle 
and  with  fibroid  tissue,  it  is  termed  "  mixed  phthisis."!  The 
presence  of  tubercle  in  the  affected  lung  cannot  always  be  dis- 
covered ;  the  disease  is  sometimes  acute,  and  involves  the  whole 

*  Principles  and  Practice  of  Physic,  by  Sir  T.  Watson,  Bart.,  M.D. 

t  Jones  and  Sieveking's  Pathological  Anatojny,  by  Payne,  1875,  p.  502. 

X  Ibid.,  p.  504. 


506  DISEASES   OF   CHILDREN. 

of  a  lung,  wlaile  in  another  it  is  more  partial  and  chronic.  It  is 
difficult,  if  not  impossible,  to  frame  definitions  whicli  shall  include 
all  these  varieties.  After  all,  they  are  merely  dift'erent  stages  of 
the  same  morbid  process  varying  in  extent  and  degree. 

The  following  is  an  interesting  case  of  catarrhal  phthisis  trace- 
able to  inflammation,  and  in  which,  as  I  have  just  stated,  the 
tubercular  condition  was  followed  by  cavities  in  both  lungs. 

M.  C ,  set.  4|,  was  admitted  into  the  Samaritan  Hospital, 

under  Dr.  Wynn  Williams,  E'ovember  4th,  1878,  with  a  tempera- 
ture of  101.8°  ;  pulse  140  ;  respiration  60.  A  year  previously  she 
had  had  whooping-cough  and  bronchitis,  follow^ed  by  diarrhoea, 
and  subsequently  failing  health.  There  w^as  a  history  of  half 
starvation,  and  the  child  w^as  wearj^  and  exhausted.  An  exami- 
nation of  the  chest  revealed  dulness  over  the  right  sternum,  loud 
tubular  breathing  mixed  with  coarse  crepitation,  and  the  voice  w^as 
bronchophonic.  The  right  lung  was  resonant  before  and  behind, 
and  the  respiration  was  exaggerated.  On  the  16th  the  morning 
temperature  was  99°,  and  the  evening  104°  ;  the  pulse  and  respi- 
ration were  the  same  as  on  admission ;  the  cough  w^as  loose,  the 
lips  were  dusky,  and  rales  were  heard  throughout  both  lungs.  On 
the  22d  the  morning  temperature  was  99°,  the  evening  102.4°, 
pulse  156,  respiration  44,  abdominal ;  the  eyes  were  dull,  and  the 
lips  dark  and  dryish.  There  had  been  slight  wandering  at  night 
since  admission.  There  was  an  enormous  accumulation  of  phlegm 
in  the  air-passages,  and  rales  were  distinctly  audible  throughout 
the  front  and  back  of  the  chest.  The  carotid  arteries  beat  actively, 
and  the  external  jugular  veins  were  distended  from  defective 
action  of  the  right  heart ;  pupils  turned  up  under  both  eyelids ; 
belly  flat ;  urine  high-colored,  but  non-albuminous ;  copious  dis- 
charge from  both  ears.  On  the  27th  there  was  loud  pneumonic 
crepitation  in  the  low^er  half  of  the  left  lang,  which  was  dull  on 
percussion  ;  above,  tubular  breathing.  There  was  subcrepitant 
rhonchus  in  the  lower  half  of  the  left  lung,  and  slight  dulness. 
There  was  a  slough  behind  the  left  ear,  over  the  mastoid  process, 
just  as  is  sometimes  seen  over  the  sacrum  in  fever.  From  this 
time  forward  to  her  death  (Deceml)er  2d)  the  temperature  did  not 
exceed  100°,  but  the  pulse  and  respiration  w^ere  unchanged. 

Fost-mortem  Examination^  twenty  hours  after  Death,  by  Mr.  Alban 
Boran. — Body  much  emaciated,  and  large  slough  around  the 
pinn?e  of  both  ears.     Lungs  studded  with  caseous  tubercle.     Ne- 


PULMONARY   CONSUMPTION.  507 

crosis  of  squamous  and  petrous  parts  of  left  temporal  bone.  The 
right  lung  was  pale  and  emphysematous.  There  was  a  slender 
old  pleural  adhesion  near  the  apex,  a  small  cavity  near  the 
apex,  and  a  calciiied  tubercular  deposit  in  the  middle  lobe,  and 
pneumonia  at  the  base.  The  left  lung  was  almost  universally 
adherent  to  the  thoracic  walls,  and  infiltrated  throughout  with 
tubercular  caseous  deposit.  There  was  a  cavity  large  enough  to 
hold  a  walnut  near  the  apex,  and  much  pneumonic  change  at  base, 
with  caseous  tubercle.  There  were  about  two  ounces  of  turbid 
serum  in  the  pericardium.  A  broken-down  lymphatic  gland  filled 
with  pseudo-pus  lay  close  in  front  of  the  aortic  arch.  The  heart 
and  brain  were  normal.  The  liver  was  large  and  studded  with 
tubercle.     The  spleen  contained  a  few  caseous  tubercles. 

Chronic  phthisis  [tuhercular  phthisis — chronic  tuberculosis)  is  the 
most  common  variety  of  consumption  that  we  meet  with.  It 
occurs  in  the  form  of  miliary  tubercle,  which  usually  selects  the 
apex  of  a  lung,  instead  of  being  thickly  disseminated  through 
both  lungs,  as  in  acute  tuberculosis;  hence  the  complaint  is  not 
so  rapid  in  its  progress,  and  there  is  a  better  chance  of  the  disease 
being  arrested,  or  followed  by  complete  recovery.  Following  these 
granulations  there  is  caseation,  which  causes  consolidation  of  the 
apex,  and  ultimately  softening  and  degeneration.  The  centre  of 
the  mass  softens  and  breaks  down  into  a  cavity,  whilst  the  cir- 
cumference becomes  harder  and  fibroid  in  its  structure.  It  is  sup- 
posed by  some  authorities  that  all  the  changes  can  occur  without 
the  presence  of  tubercle,  as  it  was  once  thought  that  all  the  mor- 
bid changes  were  primarily  due  to  tubercular  deposit.  It  is  in 
such  cases  as  these  that  we  hear  of  the  complaint  being  arrested 
in  its  first,  second,  or  third  stage,  and  cavities  remaining  quiescent 
for  many  years.  There  may  be  a  diiference  in  the  changes  which 
take  place  in  chronic  cases,  because,  whether  tubercles  form  early 
or  late,  they  are  always  complicated  with  inflammation ;  the  dis- 
ease may  begin  with  inflammation,  and  as  it  advances  become 
tubercular — tubercles  added  to  pre-existing  inflammation. 

The  destructive  process  having  begun  in  the  apex  of  the  lung 
gradually  proceeds  downwards,  and  the  cavity,  when  of  any  con- 
siderable duration,  presents  a  difterent  appearance  to  those  cavities 
which  subsequentlj^  form  in  the  centre  or  lower  parts  of  the  lung. 
The  walls  of  the  cavity  in  chronic  cases  of  pulmonary  disease  are 
dense,  tough,  and  hard;  they  are  lined  by  a  membrane  which  is 


508  DISEASES    OF    CHILDREN. 

more  or  less  vascular,  and  pours  out  a  free  secretion.  "Cavities 
thus  lined  may  continue  to  yield  for  some  time  a  purulent  secre- 
tion, which  gradually  lessens  in  quantity,  and  all  active  signs  of 
disease  elsewhere  having  abated  the  case  becomes  one  oi  '■  quiescent 
cavity.''  "*  The  process  of  destruction  having  been  arrested,  the 
dense  cartilaginous  tissue  surrounding  the  cavity  undergoes  con- 
traction, and  so  in  time  diminishes  its  area.  Those  cavities  which 
are  recent  have  no  defined  outline;  their  walls  are  ragged,  soft, 
and  irregular,  and  may  contain  pus  or  broken-down  lung-tissue. 
I  have  recorded  such  a  case  in  a  boj^,  where  the  cavities  were  very 
recent,  although  the  lung  disease  was  of  considerable  standing. f 
"  There  has  been  no  induration  of  any  part  by  the  development  of 
connective  tissue,  but  the  whole  lung  is  crowded  by  soft,  yellow, 
albuminous,  or  "scrofulous  matter,  which  has  undergone  so  rapid  a 
softening  that  the  whole  lung  resembles  a  sponge  soaked  in  puru- 
lent matter."!  In  the  case  to  which  I  have  alluded  the  whole 
lung,  except  where  the  two  cavities  existed,  had  the  appearance 
of  a  Stilton  cheese,  where  the  white  and  sage-looking  green  parts 
are  almost  equal.  It  is  a  scrofulous  material  which  tends  rapidly 
to  caseation  and  decay.  There  is  no  repair,  of  the  possibility  of 
it,  in  any  lung  so  extensively  infiltrated  with  this  deposit. 

When  these  changes  are  taking  place  in  a  chronic  cavity  of 
some  standing,  the  bloodvessels  become  impervious,  and  thickened 
by  hard  lymph,  hence  haemorrhage  does  not  occur  when  vomiting 
or  severe  coug-hinff  ensues.  The  bronchial  tubes  do  not,  fortu- 
nately,  share  the  same  fate  ;  their  destruction  proceeds  with  that 
of  the  pulmonary  tissue,  and  hence  they  remain  pervious.  It  is 
through  them  that  the  products  of  ulceration  and  suppuration 
make  their  way  out  of  the  system. 

Fibroid  -phthisis  [cirrhosis  of  the  lung — Corrigan)  is  that  variety 
in  which  the  consolidation  of  the  lung  has  undergone  a  fibrous  in- 
duration ;  it  is  tough,  and  becomes  contracted  when  the  pulmonary 
tissue  is  compressed  from  pleuropneumonia,  so  that  no  exudation 
is  thrown  out  into  the  air-cells,  and  the  plastic  matter  is  confined 
to  the  interstitial  texture  ;  if  not  reabsorbed  it  leads  to  contrac- 

*  Clinical  Lectures  on  Excavation  of  the  Lung  in  Phthisis,  by  R.  Douglas  Powell, 
M.D.,  The  Lancet,  1877,  vol.  i,  p.  523. 
t  The  Lancet,  1879,  vol.  ii,  p.  504. 
X  Pathological  Anatomy,  by  Wilks  and  Moxon,  1875,  p.  344. 


PULMONARY   CONSUMPTIOX.  509 

tion  and  consolidation.*  In  this  disease  the  bronchi  are  dilated, 
because  as  the  air  enters  the  chest  it  cannot  obtain  admission  into 
the  air-cells.f  Hughes  Bennett,  Addison,  Wilson  Fox,  Bartels, 
and  other  authorities,  have  shown  that  dilatation  of  the  bronchi 
is  a  common  consequence  of  bronchopneumonia  in  children,  and 
that  this  dilatation  disposes  to  thickening  around  the  bronchi,  and 
to  induration  of  the  pulmonary  tissue.  The  parts  surrounding 
cavities  are  often  dense  and  firm,  "  and  the  process  of  cicatrization 
of  such  cavities  is  almost  always  aifected  by  the  production  and 
contraction  of  a  iibrous  tissue  of  a  similar  character.":!:  The  dis- 
ease may  arise  from  pneumonia,  or  from  pleuropneumonia,  when 
the  effusion  thrown  out  into  the  interstitial  texture  of  the  luns: 
becomes  transformed  into  a  tough  fibrous-like  tissue.  "  Fibroid 
lesions  may  arise  from  interlobular  inflammations,  from  long-con- 
tinued chronic  bronchitis,  from  the  extension  of  dry  pleurisies  into 
the  lung,  and  from  the  transformation  of  pneumonic  exudations. 
They  produce  contraction  and  induration  of  the  lung,  and  occa- 
sionally dilatation  of  the  pulmonary  tissue  of  the  bronchial  tubes. 
Sometimes  fibroid  lesions  lead  to  caseous  pneumonia  and  to  '  tu- 
bercles;' more  frequently  they  occur  alone.  Their  clinical  history 
is  characteristic  ;  it  is  slow  in  its  progress,  apyretic  in  character, 
and  sooner  or  later  produces  albuminuria  and  dropsy. "§ 

Dr.  Pollock  states  that  '-'■  Bronchitis  is  a  less  common  origin  of 
fibroid  changes,  but  it  is  observed  in  children  and  others  ;  in  the 
former  after  pertussis  or  rubeola,  when  collapse  of  a  portion  of 
lung  is  apt  to  occur,  followed  by  contractile  fibroid  proliferation."!] 
Dr.  Wilson  Fox  also  writes :  "  If  we  consider  the  course  of  acute 
bronchitis  in  children,  and  recollect  how  constantly  dilatation  of 
the  bronchi  occurs  in  this  condition,  both  in  the  idiopathic  form 
of  the  disease,^  and  also  in  the  course  of  measles  and  whooping- 
cough,  it  can  only  be  a  subject  of  surprise  that  permanent  lesions 
of  this  nature  are  not  more  commonly  met  with  as  the  results  of 
these  diseases."T[ 

This  sequence  of  events  looks  very  much  like  the  blood  having 
also  undergone  some  important  changes.    "  But  there  is  also,  prob- 

*  Jones  and  Sieveking's  Pathological  Anatomy,  by  Payne,  1875,  p.  502. 

t  Ibid. 

X  Pulmonary  Consumption,  by  Drs.  C.  J.  B.  and  C.  Theodore  Williams,  1871,  p.  37. 

§  Prefatory  Note  on  Phthisical  Lesions  of  the  Lungs,  by  Dr.  Andrew  Clark,  1S77. 

II  Clinical  Demonstrations  of  Phthisis,  The  Lancet,  1876,  vol.  ii,  p.  566. 

^  Reynolds's  System  of  Medicine,  article  Chronic  Pneumonia,  vol.  iii,  p.  756. 


510  DISEASES    OF   CHILDREIf. 

ably,  a  peculiar  fibrinous  state  of  tbe  blood,  wbich  Rokitansky 
calls  2i  fibrinous  crasis^  in  certain  cases,  rendering  tbe  products  of 
inflammation  more  fibrinous  tban  usual,  and  with  smaller  propor- 
tion of  the  corpuscular  element ;  and  tending,  therefore,  to  pro- 
duce more  fibroid  or  contractile  tissues,  and  less  of  the  purulent 
and  opaque  curdy  deposits  which  originate  in  the  corpuscles  or 
sarcophytes."*  There  may  be  differences  of  opinion  as  to  the  man- 
ner in  which  the  disease  originates,  but  the  tendency  is  to  cause 
contraction  and  induration  of  the  texture  in  which  the  morbid 
matter  is  deposited,  and  sometimes  to  be  followed  by  caseation 
and  cavities  in  the  lungs.  The  bronchial  tubes  also  become  dilated 
or  contracted  according  to  the  part  of  the  lung  which  is  chiefly 
affected.  When  the  lower  part  is  invaded  the  air  cannot  get  be- 
yond the  larger  tubes,  and  so  the  pressure  of  the  inspired  air  dilates 
them ;  while,  at  the  upper  part,  the  tubes  are  contracted  from  the 
shrinking  of  the  lung  towards  the  spinal  column,  the  collapsed 
state  of  the  chest-wall,  and  the  displacement  of  the  heart  up- 
wards. 

"  In  characteristic  cases  of  this  nature,  the  cut  surface  of  the 
lung  is  smooth  and  glistening  ;  it  is  hard,  and  creaks  like  carti- 
lage, or  resembles  the  tissue  of  the  uterus.  It  tears  with  the 
greatest  difficulty,  and  no  longer  presents  the  granular  appear- 
ance of  ordinary  pneumonia.  No  fluid  can  usually  be  expressed 
from  this  tissue."  f 

The  constitutional  symptoms  of  phthisis  in  some  cases  are  slow 
and  insidious;  they  are  frequently  overlooked  till  attention  is 
invited  to  the  chest,  and  then  the  presence  of  physical  signs  is  too 
often  conclusive.  Illness  has  begun  with  slight  catarrh,  bron- 
chitis or  pleurisy,  or  pneumonia,  and  the  child  has  not  been  well 
after  it.  It  gets  a  severe  cold,  followed  by  pain  in  the  chest, 
cough,  and  quick  breathing;  it  improves  for  a  time,  and  then 
gets  another  cold,  which  is  more  obstinate,  and  if  any  expectora- 
tion is  seen  it  is  opaque,  and  perhaps  streaked  with  blood.  As 
the  case  goes  on,  the  temperature  rises  towards  evening,  sleep  is 
disturbed  at  night,  and  the  pulse  and  respiration  are  habitually 
quick.  If  the  child  loses  appetite  it  wastes  rapidly,  there  is  thirst, 
it  is  fretful  and  irritable  ;  the  bowels  are  irregular,  constipation  is 
often  present  at  an  early  stage,  and  diarrhoea  later  on.      The 


*  Pulmonary  Consumption,  by  Drs.  C.  J.  B.  and  C.  Tlieodore  Williams,  1871,  p.  63. 
f  Wilson  Fox,  op.  cit.,  p.  767. 


PULMONARY   CONSUMPTION.  511 

motions  are  greenish  and  loose,  or  clayey  and  offensive,  and  the 
abdomen  is  often  large.  In  a  case  of  chronic  tuberculosis  in  a 
child  6|  years,  who  came  under  my  care  in  1875,  the  illness  had 
only  become  observable  to  her  friends  a  fortnight  before  I  saw 
her ;  but  the  child  was  strumous  and  delicate-looking,  and  had 
been  kept  hard  at  ber  lessons  till  she  broke  down.  Sbe  was  fast 
losing  flesh,  and  was  burnt  up  with  fever  at  night,  yet  there  were 
no  chest  symptoms,  and  no  cough  or  expectoration  ;  the  pulse 
averaged  120,  morning  temperature  99°,  evening  101°.  Sbe 
remained  under  treatment  for  six  months,  and  when  I  saw  her 
then  she  had  not  improved ;  there  was  a  little  cough,  a  pulse 
habituall}^  quick,  and  a  temperature  always  above  normal  in  the 
evening. 

Hmmopiysis  is  another  important  sj^mptom,  but  it  is  not  frequent 
among  children  as  a  sj^mptom  of  phthisis.  Still  it  does  occur  now 
and  then,  especially  where  tubercular  or  pneumonic  consolidation 
is  breaking  down.  In  an  early  stage  it  is  due  to  active  hyper?emia, 
to  an  undue  determination  of  blood  to  the  congested  mucous  mem- 
brane, and  not  to  venous  obstruction.  In  advance  phthisis  it 
arises  from  aneurisnial  dilatation  of  branches  of  the  pulmonary 
artery  being  ruptured,  and  is  rarely  bronchial,  whereas,  in  early 
phthisis,  it  is  generally  bronchial.*  In  bronchopneumonia  and 
whooping-cough  a  little  blood  is  frequently  coughed  up  from 
overdistension  or  fragility  of  the  capillaries,  and  the  patient  is 
none  the  worse  for  it.  I  have  known  a  child,  3|  years  of  age, 
born  of  consumptive  parents,  and  suffering  from  tuberculosis, 
bring  up  at  one  time  a  tablespoonful  of  blood,  a  j-ear  before  any 
other  chest  symptoms  were  noticed.  This  haemorrhage  was  then 
folloAved  by  loss  of  flesh,  intense  thirst,  and  febrile  exacerbations 
towards  evening.  Small  mucous  rales  were  detected  over  the 
front  of  the  chest  and  below  the  spine  of  the  right  scapula,  which 
area  was  also  dull  on  percussion.  There  was  harassing  cough, 
and  thick  sputa  were  coughed  up,  occasionally  tinged  with  blood. 
Haemorrhage  from  the  lung  would  seem  to  have  been  the  starting- 
point  in  this  case — the  real  cause  of  the  lung  destruction.  "  Our 
experience  of  many  thousand  cases  has  led  us  to  conclude  that 
haemoptysis  to  the  extent  of  more  than  a  drachm — in  a  person 
free  from  the  hsemorrhagic  diathesis,  from  cancerous  disease  of 
the  lung,  injury  to  the  chest,  disease  of  the  heart,  and  from  disor- 

*  Dobell,  op.  cit.,  p.  20. 


512  DISEASES   or   CHILDREIS". 

der  of  the  uterus — is  indicative  of  a  fragile  state  of  the  vessels  of 
the  lungs,  closely  connected  with,  and  generally  arising  out  of, 
consumptive  disease  of  these  organs."* 

Hemoptysis  is  less  copious  in  the  first  than  in  the  third  stage 
of  the  disease.  Dr.  Douglas  Powell  has  recorded  a  fatal  case  of 
haemoptysis  in  an  infant  seven  months  old.  Five  other  children 
of  the  same  family  had  all  died  consumptive,  the  father  had  chest 
disease,  and  the  grandfather  died  of  phthisis  at  thirty-three. 
"  Without  having  had  any  previous  attack  of  haemoptysis,  the 
infant  suddenly  expectorated  more  than  half  a  pint  of  dark  clot- 
ted hlood,  and  died  almost  immediately.  On  a  post-mortem 
examination  the  surfaces  of  both  lungs  were  studded  with  sub- 
pi  eural  gray  miliary  granulations  of  tubercle,  and  the  lungs,  on 
section,  were  also  found  to  be  disseminated  with  gray  granula- 
tions."f  It  has  also  been  stated,  in  corroboration  of  Memeyer's 
view,  that  in  cases  of  severe  haemoptysis  portions  of  blood  are 
drawn  into  the  alveoli,  which  they  occupy  as  fibrinous  nodules, 
and  that  these  may  set  up  irritation,  produce  a  calcareous  mass, 
or  even  cause  laceration  of  the  pulmonary  tissue  and  cavities.J 

The  physical  signs  of  phthisis  ought  to  be  carefully  studied, 
because  they  throw  light  upon  the  general  symptoms  of  the  dis- 
ease, and  strengthen  our  diagnosis,  when  the  indications  afitbrded 
by  either  alone  might  leave  us  uncertain.  Phthisis  is  both  a  con- 
stitutional and  a  local  malady — constitutional  in  the  sense  that  it 
has  a  preliminarj'  stage,  if  I  may  so  term  it,  and  the  patient  may 
be  consumptive  without  any  tubercle  in  the  lung.  The  local 
change,  when  it  does  ensue,  is  the  eftect  of  the  constitutional 
taint.  Many  children  present  all  the  general  characteristics  of 
pulmonary  consumption — wasting  of  flesh,  quick  pulse,  and  har- 
assing cough,  and  yet  the  chest  affords  no  evidence  of  disease; 
the  resonance  is  not  impaired  ;  the  breathing  is  clear. 

I  have  before  said  that  tubercle  tends  to  diflfusion  in  young 
subjects  rather  than  to  concentrate  itself  on  the  apices  of  the  lungs, 
as  it  does  in  adults.  Still  we  occasionally  encounter  cases  in  young 
subjects  where  the  morbid  changes  do  not  extend  to  the  base  of 

*  Pulmonary  Consumption,  by  Drs.  J.  C.  B.  and  C.  Theodore  Williams,  1871, 
p.  145. 

t  Path.  Trans.,  1S74,  p.  40. 

X  Pathological  Traces  of  Pulmonary  IIa?morrhage,  by  Reginald  E.  Thompson, 
M.D.,  Med.-Chir.  Trans.,  1873,  vol.  Ixi,  p.  2G1. 


PULMONARY   CONSUMPTION.  513 

the  lungs,  or  if  tubercle  is  scattered  extensively  through  them,  it 
mainly  involves  the  upper  lobes,  and  softening  takes  place  before 
the  patient  has  lived  long  enough  for  the  like  destruction  to  ensue 
in  the  lower  lobes. 

We  shall  speak  of  three  stages  of  the  disease: 

1.  That  of  deposit. 

2.  That  of  consolidation  and  softening. 

3.  That  of  suppuration,  when  cavities  form. 

Space  will  not  admit  of  fully  considering  all  the  signs  which 
various  authorities  have  from  time  to  time  held  to  indicate  con- 
sumption. I  am  bound  to  admit  that  my  own  experience  concurs 
with  those  who  are  unable  to  declare  whether  mere  feebleness  or 
harshness  of  breathing,  imperfect  expansion  of  the  chest,  loudness 
of  the  heart's  sounds,  or  bronchophony,  are,  any  one  of  them,  taken 
singly,  reliable  indications  of  tubercular  disease.     I  think  not. 

Although  it  is  important  to  examine  the  chest  carefully  through- 
out both  in  front  and  behind,  the  upper  portions  of  the  lung  above 
and  below  the  clavicles,  and  the  suprascapular  spaces,  should  never 
be  overlooked.  The  interscapular  region  too  often  affords  evidence 
of  enlarged  bronchial  glands,  which  may  serve  to  clear  up  any 
doubt. 

First  Stage. — Looking  at  ordinary  cases  as  we  meet  with  them 
in  practice,  the  earliest  indications  of  a  deposit  of  tubercle  in  the 
pulmonary  tissue  are  an  alteration  in  the  breath-sounds ;  the  inspi- 
ratory murmur  is  weak,  harsh,  jerking,  or  bronchial,  and  the  expi- 
ration (which  is  far  more  significant)  is  loud  and  unduly  prolonged. 
Merc  weakness  of  breathino;  does  not  ero  far  as  a  dias-nostic  sio;n, 
as  it  occurs  in  many  cases  of  general  debility,  and  disappears  with 
improved  health.  It  may  arise  in  consequence  of  a  narrowing  or 
obstruction  of  the  bronchioles,  pleuritic  effusion,  thickening  of  the 
pleura,  and  emphysema,  which  impair  the  elasticity  of  the  lungs.* 
A  comparison  of  the  two  sides  of  the  chest  is  the  only  test  of  its 
quality,  since  it  is  very  rare  to  lind  both  lungs  similarly  involved. 

Harshness  of  breathing  is  another  sound  at  variance  with  the 
softness  of  health,  and  when  also  rough  or  blowing  it  passes  into 
bronchial  breathing  with  moist  sounds.  It  arises  from  thickening 
and  loss  of  elasticity  in  the  air-cells,  and  also  from  a  dry  condition 
of  the  bronchial  membrane. 

*  Clinical  Demonstrations  of  Phthisis,  by  J.  D.  Pollock,  M.D.,  the  Lancet,  vol.  ii, 
1876,  p.  179. 

33 


514  DISEASES   OF   CHILDREN. 

When  there  is  a  change  in  the  quality  of  the  breathing,  and  the 
expiration  is  prolonged,  it  may  be  considered  to  indicate  commenc- 
ing mischief.  In  some  states  of  debility  among  children,  and  in 
bronchitis  and  emphysema,  audibility  and  lengthening  of  the  ex- 
piratory murmur  are  not  uncommon.  This  is  very  apparent  in 
thin  exhausted  subjects  when  they  allow  the  air  to  escape  from 
the  lung  by  a  sudden  or  spasmodic  effort,  as  they  often  will  do 
when  the  chest  is  being  examined.  We  have  all  observed  in  prac- 
tice how  short  the  inspiration  is,  compared  to  expiration,  in  fat 
and  feeble  subjects,  when  the  heart  is  weak  and  the  patients  are 
breathless  from  flatulence  or  exertion. 

Jerking^  wavy^  or  interrupted  respiration  is  only  valuable  as  a 
means  of  diagnosis  when  taken  in  connection  with  other  signs. 
Alone  it  is  unimportant. 

Changes  in  the  form  and  movements  of  the  thoracic  walls  are 
worthy  of  careful  observation,  as  throwing  much  light  on  the  con- 
dition of  the  lung.  When  the  patient  is  placed  in  a  suitable  posi- 
tion, and  the  hand  is  laid  over  the  sternum  during  inspiration,  a 
comparison  of  the  two  sides  can  easily  be  made,  and  any  inequality 
of  expansion  is  detected  through  the  amount  of  tubercular  deposit. 
The  other  retrogressive  changes  are  the  sinking-in  of  the  thoracic 
walls,  the  cup-shaped  depression  below  the  clavicle,  the  rounded 
shoulders,  the  bent  form,  the  contracted  chest,  and  the  distorted 
spine. 

Dulness  on  percussion  is  another  diagnostic  sign  on  which  great 
reliance  has  been  placed,  and  it  sometimes  comes  to  our  aid  ;  but 
it  is  not  always  present,  as  I  have  pointed  out  in  enumerating  the 
physical  signs  of  tuberculosis.  There  may  be  considerable  tuber- 
cular deposit  scattered  through  the  pulmonary  tissue  without 
causing  any  dulness  whatever.  Still  in  that  variety  of  phthisis  in 
which  there  is  a  localized  deposit  of  tubercle  in  the  apex  of  a  lung, 
there  is  diminished  resonance  or  heightened  pitch. 

Vocal  fremitus  is  another  physical  sign  to  be  remembered.  It  is 
dependent  on  the  extent  of  pulmonary  condensation  beneath  the 
thoracic  walls,  but  it  is  not  always  present,  and  there  are  usually 
other  signs  of  more  significant  import.  Children's  chest-walls 
are  thin,  and  the  normal  vibrations  are  readily  conveyed  through 
them ;  fremitus,  therefore,  is  often  present  when  there  is  no  dis- 
ease. "  We  may,  I  think,  conclude  that  whenever  there  is  an  equal 
amount  of  vocal  fremitus  in  both  infraclavicular  regions  the  left 


PULMONARY   CONSUMPTION.  515 

Side  probably  \s  diseased  ;  and  that  whenever  the  vibration  is  greater 
on  the  left  than  the  opposite  side  it  is  almost  certainly  so."*  Re- 
garding broncho[)hon3',  another  valuable  sign,  the  same  writer 
remarks :  "  If  there  be  an  equal  amount  of  bronchoj)hony  in  both 
infraclavicular  regions,  the  left  is  probably  morbid ;  and  if  there 
be  a  positive  excess  on  the  left  side,  it  is  almost  certainly  so ;  a 
greater  development  of  vocal  resonance,  however,  on  the  right 
side,  is  no  indication  of  tubercular  deposit,  although  it  may  be 
looked  upon  suspiciously  should  the  excess  be  very  highly  marked. "f 
Undue  propagation  of  the  heart's  sounds,  subclavian  or  pulmonary 
murmurs,  are  all  signs  of  some  assistance  in  suspected  tubercular 
consolidation. 

Moist  sounds  heard  at  the  apex  of  a  lung  at  the  seat  of  tuber- 
cular deposit  are  very  significant.  There  is  a  sound  called  dry 
crackling  rhonchus,  which  is  regarded  as  conclusive  evidence  of 
tubercle.  It  is  a  dry  and  crackling  sound,  generally  heard  during 
inspiration,  and  indicates  an  advanced  condition  of  i\\Q first  stage. 
These  crackles  are  at  most  three  or  four  in  number,  and  are  pro- 
duced external  to  the  air-cells ;  they  are  not  always  heard,  and 
they  are  succeeded  by  a  moist  kind  of  crackling.  The  sound  is 
not  unlike  suhcrepitant  rhonchus,  which  is,  however,  moist  and 
bubbling,  and  can  scarcely  be  mistaken  for  it.  Suhcrepitant  rhon- 
chus, however,  succeeds  it,  and  if  heard  at  the  apex  is  very  sig- 
nificant, although  if  bronchitis  be  present  it  may  be  heard  at  the 
base  also.  This  sound  passes  into  humid  crackling.  If  there  is 
dry  cough,  a  little  flocculent  expectoration,  with  febrile  symptoms 
and  any  loss  of  flesh,  the  early  stage  of  phthisis  is  confirmed.  Dr. 
Pollock  has  known  the  stage  of  deposit  to  remain  quiescent  over 
and  over  again  for  fifteen  or  twenty  years.:}: 

If  phthisis  is  the  consequence  of  bronchitis,  the  signs  of  the 
latter  disease  are  increased,  rhonchus  of  a  sonorous  or  sibilant 
character  is  heard  below  the  clavicles  and  over  the  greater  part  of 
the  sternum,  as  well  as  between  the  scapulae.  If  these  sounds  are 
persistent,  and  are  more  heard  at  the  upper  portions  of  the  lungs 
than  at  the  lower,  they  are  suspicious  of  early  phthisis,  especially 
if  the  resonance  on  percussion  is  impaired  in  places.  If  also  suh- 
crepitant rhonchus  accompanies  the  expiratory  as  well  as  the  in- 


*  Phthisis  and  the  Stethoscope,  by  E.  Payne  Cotton,  M.D.,  1864,  p.  35. 
t  Ibid.  X  Op.  cit.,  p.  179. 


516  DISEASES   OF   CHILDREN. 

spiratory  murmur  (whicb,  according  to  Dr.  AYilliams,  fhe  crepita- 
tion of  pneumonia  never  does),  then  this  view  is  the  more  suspicious.* 

Crepitation  is  a  sign  of  obstruction  to  the  entrance  of  air  into 
the  puhnonarj^  tissue  in  consequence  of  swelling,  or  the  presence 
of  secretion  in  the  air-cells.  When  phthisis  is  the  result  of  acute 
pneumonia,  the  dulness  on  percussion  continues,  and  there  are 
bronchophony  and  tabular  breath-sounds.  After  a  time  this 
chronic  consolidation  undergoes  change  into  iibroid  or  caseous 
matter,  in  the  one  case  contracting,  and  in  the  other  breaking  down 
into  one  large  cavity,  or  several  small  cavities. 

Second  Stage. — The  physical  signs  announcing  the  commence- 
ment of  the  second  stage,  or  that  of  softened  tubercle,  are  much  the 
same  as  those  already  described.  Seeing  tbat  the  first  stage  may 
continue  for  an  indefinite  time,  it  is  difiicult  to  draw  the  exact  line 
of  demarcation  between  them.  A  tubercular  mass  may  reach  a 
considerable  size  in  one  case  and  produce  extensive  disease  of  the 
lung  and  pleura  before  it  begins  to  soften,  whilst  in  another  case 
degeneration  takes  place  in  the  mass  at  an  early  period.  A.  very 
important  sign  of  this  stage,  particularly  if  it  is  at  all  advanced, 
is  increased  dulness  on  percussion  of  the  afi*ected  side,  and  the  note 
has  sometimes  that  particular  jarring,  hard,  dull  sound  which  is 
termed  '■'■wooden.''  It  is  not  a  frequent  sound.  It  seems  to  be 
produced  only  when  consolidated  lung  is  bound  to  the  thoracic 
wall  by  thickened  pleura  (Cotton). 

There  is  another  sound,  called  humid  crackling  rhonchus,  which 
may  or  may  not  be  preceded  by  dry  crackling.  It  consists  of  a 
few  moist,  large,  clear,  abrupt,  clicking  sounds,  of  varying  in- 
tensity, generally  during  inspiration,  but  they  may  be  heard  dur- 
ing expiration  also,  masking  both  acts  ;  this  clicking  is  also  due  to 
softened  tubercle — to  destruction  of  lung  tissue,  and  when  once 
heard  cannot  well  be  confounded  with  subcrepitant  rhonchus, 
which  is  of  a  bubbling  character  ;  and  if  the  two  sounds  are  pres- 
ent at  the  same  time,  w'hich  is  possible  if  there  is  congestion  or 
inflammation  around  the  softened  lung,  the  distinction  between 
them  is  all  the  easier.  This  click  in  the  course  of  time  becomes 
louder,  moister,  and  more  or  less  wxtallic^  subsequently  passing 
into  the  third  stage,  or  that  of  gurgling  rhonchus.  AVhen  the^ 
clicks  are  slow  and  few,  and  occur  at  intervals,  the  mischief  in  the 

*  Pulmonary  Consumption,  1875,  p.  169. 


PULMONARY    CONSUMPTION.  517 

lung  proceeds  mucli  slower  than  when  they  are  large,  metallic, 
mucous,  and  loose. 

In  this  stao'e  there  is  often  wasting  and  loss  of  flesh. 

As  we  have  seen,  there  is  a  difficulty  in  separating  the  first  from 
the  second  stage  of  phthisis,  so  there  is  an  equal  difficulty  in  de- 
finino;  the  termination  of  the  second  stage  and  the  commencement 
of  the  third. 

Third  Stage. — This  is  reached  when  a  vomica,  however  small,  is 
present.  ISTow^  the  clavicle  on  the  aflected  side  is  more  promi- 
nent, and  the  hollow  beneath  it  is  deeper  and  more  cup-shaped 
towards  its  acromial  end.  On  deep  inspiration  the  lower  part  of 
the  chest-wall  is  elevated,  suddenly  raised,  as  it  were,  by  the  con- 
traction of  the  diaphragm ;  the  forced  muscles  of  inspiration 
come  into  play,  whilst  the  upper  part  of  the  sternum  is  barely 
expanded  at  all,  and  the  hand  may  not  be  elevated  on  the  deepest 
inspiration. 

Gurgling  rhonchus  is  a  moist,  large,  bubbling,  metallic  sound, 
heard  during  the  act  of  inspiration  and  expiration  when  the  cavity 
is  small.  It  is  the  final  stage  of  the  humid  crackling  and  large 
subcrepitant  rhonchus  which  have  been  already  explained.  The 
percussion-sound  is  necessarily  subject  to  great  variation,  accord- 
ing to  the  state  of  the  lung,  the  adhesions  that  have  been  formed, 
the  force  employed  in  striking  the  thoracic  wall,  and  the  size  of 
the  cavity.  The  note,  from  being  absolutely  dull  or  "  wooden^^ 
is  sometimes  scarcely  altered  from  that  of  health.  I  have  known 
the  infraclavicular  region  of  a  child  approach  healthy  resonance, 
when  the  sounds  elicited  by  auscultation  and  the  depressed  and  inac- 
tive state  of  the  chest-wall  have  confirmed  the  last  stage  of  phthisis. 
When  I  relied  mainly  on  percussion  as  a  means  of  diagnosis,  I 
was  often  in  doubt  as  to  the  state  of  the  lung.  When  the  vomica 
is  large,  and  situated  near  the  chest-wall,  or  only  separated  from 
it  by  thickened  pleura  or  lung,  the  percussion-note  has  a  peculiar 
hollow-like  resonance,  which  has  acquired  the  expressive  term 
amphoric.  When  this  sound  is  present,  a  modification  of  it,  called 
the  cracked-pot  sound  {bruit  de  pot  fete),  first  described  by  Laennec, 
may  sometimes  be  heard,  if  the  chest  over  a  cavity  is  struck  sud- 
denly, rather  forcibly  and  abruptly,  whilst  the  patient's  mouth  is 
kept  open.  This  peculiar  sound  can  only  be  produced  when  the 
cavity  is  large,  and  freely  communicates  with  the  bronchial  tubes. 
"In  children,  however — the  subjects  of  bronchitis  or  emphysema, 


518  DISEASES    OF    CHILDREN. 

and  even  sometimes  when  in  perfect  liealtli — the  natural  percus- 
sion now  and  then  bears  a  very  close,  or  even  a  complete,  resem- 
blance to  the  cracked-pot  sound  ;  so  that  in  patients  who  are  young 
— say  under  ten,  or  at  most  twelve,  years  of  age — this  sign  is  of 
no  value  in  diagnosis,  unless  accompanied  by  other  evidence  of  the 
presence  of  a  vomica,"*  and  unless  it  contrasts  strongly  with  the 
other  side  of  the  chest. 

A  cavity  may  form  so  gradually  in  the  lung,  and  the  process  of 
disintegration  may  be  so  slow  as  to  escape  notice,  till  the  character 
of  the  breathing  decides  the  doubtful  point. 

"When  there  is  a  cavity  in  the  lung,  the  expiration  may  assume 
a  hollow,  blowing,  metallic  quality,  termed  cavernous ;  and  if  the 
cavity  is  large  it  may  possess  an  amphoric  quality,  a  sound  which 
resembles  blowing  into  an  empty  bottle.  Cavernous  respiration  is 
not  unlike  bronchial  respiration,  but  the  latter  is  heard  over  a 
greater  extent  of  lung,  it  is  rougher  in  quality,  and  is  wanting  in 
the  metallic  type  so  characteristic  of  the  former.  If  a  cavity  con- 
tains much  purulent  matter,  or  the  bronchial  tubes  opening  into 
it  are  clogged  up,  and  the  patient  is  very  feeble,  it  may  escape 
notice  altogether.  The  gurgling  rhonchus,  too,  when  it  is  large  or 
bubbling,  according  to  the  amount  of  secretion,  may  also  obliterate 
the  cavernous  character  of  the  breathing.  Coughing  will  often 
throw  much  light  upon  obscure  symptoms.  "  It  is  oftentimes  by 
no  means  easy  to  detect  the  vomica  of  very  young  children.  In 
such  little  patients  the  natural  respiration  over  the  entire  chest  is 
usually  so  blowing,  that  it  is  apt  completely  to  mask  the  cavernous 
character  of  any  particular  spot.  All  the  physical  signs,  indeed, 
but  especially  those  derived  from  percussion,  and  the  ausculta- 
tion of  the  breathing,  are,  in  young  children,  at  their  minimum. 
Cavernous  rhonchus,  when  it  exists  in  these  cases,  is,  perhaps,  the 
best  help  to  diagnosis,  being  less  likely  than  any  other  sign  to  be 
either  obscured  or  overlooked."f 

31etallic  tinkling  is  sometimes  heard  when  the  vomica  is  very 
large  and  contains  fluid ;  but  I  never  remember  to  have  seen  an 
instance  in  a  child,  owing  perhaps  to  the  rarity  in  them  of  tuber- 
cular excavation.  Pectoriloquy,  for  the  like  reason,  is  not  a  fre- 
quent sign. 

Elastic  tissue  is  sometimes  detected  in  the  expectoration  of 

*  Phthisis  and  the  Stethoscope,  by  R.  Payne  Cotton,  M.D.,  1864,  p.  72. 
f  Phthisis  and  tlie  ytethoscoi^e,  18G4,  p.  8-4. 


PULMONABY   CONSUMPTIOiSr,  519 

plithisical  persons  who  have  cavities  in  their  kings,  hut  it  is  not 
alwaj'S  found.  The  best  method  of  proceeding  is  to  boil  the  sputa 
with  a  solution  of  caustic  soda,  and  then  to  examine  the  deposit 
under  the  microscope.  "  Bronchial  tubes  may  be  recognized  by 
their  branching  form,  and  are  sometimes  accompanied  by  frag- 
ments of  bloodvessels.  When  only  small  crepitations  can  be  heard 
in  the  lungs,  the  greater  part  of  the  deposit  will  be  found  to  con- 
sist of  air-cells ;  where  the  signs  of  a  cavity  are  present  you  will 
meet  with  portions  of  the  bronchial  tubes  in  the  sputa  ;  fragments 
of  the  bloodvessels  can  be  rarely  detected  excepting  just  before  or 
during  an  attack  of  hperaoptysis."* 

The  physical  signs  of  the  tubercular  form  of  acute  yh.thisis  have 
been  considered  when  treatins;  of  this  ati'ection  under  the  latter 
heading. 

Phthisical  Laryngitis. — AVhen  the  larjmgeal  mucous  membrane  is 
ulcerated,  the  respiration  over  the  trachea  is  harsh  and  loud,  and 
the  voice  is  changed  to  a  whisper  in  some  cases.  With  these 
symptoms  those  of  ordinary  phthisis  are  generally  present. 

Causes. — These  are  predisposing  and  exciting.  Among  the  for- 
mer the  tubercular  or  phthisical  diathesis  is  to  be  noticed,  with 
its  light  hair  and  eyes,  fair  skin,  long  eyelashes,  and  thin  lips ;  so 
that,  looking  at  the  matter  from  a  hereditary  point  of  view,  we 
know  when  a  child  has  inherited  a  scrofulous  constitution  or  has 
come  of  tuberculous  parents  ;  the  disease  under  these  circumstances 
is  readily  lighted  up  on  slight  provocation.  Residence  on  a  wet 
soil  or  in  badly- ventilated  homes  may  induce  it.  It  is  a  remarkable 
circumstance  that  phthisis  is  not  found  in  certain  countries  and 
localities.  Dr.  Leared  says:  "In  Iceland  no  phthisis  exists;  the 
atmosphere  is  cold  and  clear,  and  the  inhabited  parts  are  not  much 
above  the  level  of  the  sea.  In  jNIorocco,  where  there  is  also  no 
phthisis,  the  atmosphere  is  the  reverse  of  Iceland,  and  the  soil  is 
sandy  ;  there  is  also  no  phthisis  in  the  valley  of  the  Jordan,  which 
is  eighty  to  ninety  feet  below  the  level  of  the  Mediterranean,  and 
the  atmosphere  of  these  three  places  is  totally  different  from  that 
of  Davos. "t  Dr.  J.  H.  Bennett  also  writes :  "  It  is  worthy  of  re- 
mark that  the  inhabitants  of  Iceland,  living  in  a  most  unhygienic 
state,  filth}'  in  person  and  habits,  and  cooped  up  in  badly- ventilated 
huts,  are  said  to  be  all  free  from  consumption,  and  from  other  forms 

*  Medical  Diagnosis,  by  Dr.  Fenwick,  1876,  p.  S3, 
f  Med.  Soc.  Proc.,  vol.  iv,  p.  259. 


520  DISEASES   OF   CHILDEElSr. 

of  tubercular  disease.  This  fact  is  not  improbabl}^  connected  with 
their  great  consumption  of  oil  as  an  article  of  diet."* 

Among  the  exciting  causes,  we  must  consider  the  effect  of  pre- 
vious inflammation  of  the  lungs,  frequent  catarrh,  hereditary- 
syphilis,  prolonged  ansemia,  and  exhausting  illness  following  the 
eruptive  fevers. 

Diagnosis  from  Typhoid  Fever. — Acute  phthisis  is  attended  with 
such  high  fever  that  at  an  early  period  of  the  illness  it  may  be 
mistaken  for  typhoid.  The  chief  diagnostic  differences  are  the 
natural  form  of  the  abdomen,  the  absence  of  the  rose  spots,  gur- 
gling in  the  right  iliac  fossa,  and  constipation  rather  than  diarrhoea. 
Then,  too,  the  cough,  livid  countenance,  and  dyspnoea,  point  to  the 
chest  as  the  primary  source  of  mischief. 

Treatment. — In  considering  the  treatment  of  tuberculosis  and 
the  arrest  or  absorption  of  tubercle,  we  must,  in  a  measure,  disre- 
gard the  varied  and  special  symptoms  of  the  disease,  and  sustain 
and  support  the  general  strength.  The  nutritive  functions  being 
primarily  at  fault  demand  the  closest  attention,  and  whatever  con- 
duces to  their  healthy  performance  holds  out  the  best  means  of 
controlling  morbid  action,  and  of  averting  the  tendency  to  local 
congestion  .and  exudation ;  for  when  these  changes  have  occurred, 
the  molecules  or  granular  matter  of  which  the  exudation  consists 
are  liable  to  lead  to  softening  and  disintegration. 

As  cases  of  tuberculosis  differ  like  other  forms  of  consumptive 
disease,  remedies  of  a  varied  character  are  required.  In  some 
instances  in  children  the  temperature  of  the  body  is  high  at  an 
early  stage  of  the  illness,  and  the  circulation  is  accelerated  ;  there 
is  thirst  and  derangement  of  the  gastro-intestinal  tract,  and  food 
is  not  digested,  even  if  there  is  any  remnant  of  appetite  left. 
Antiphlogistic  measures  and  cooling  drinks  to  subdue  this  febrile 
excitement  are  absolutely  required.  We  have  seen  how  frequently 
bronchitis  or  pneumonia  is  associated  with  this  condition,  and 
when  they  are  met  with,  salines  and  diaphoretics  are  i-equired 
before  supporting  measures  can  be  safely  employed.  If  the  cough 
is  hard  and  tearing,  and  there  is  soreness  and  constriction  of  the 
chest,  a  tonic  and  stimulating  plan  would  aggravate  the  condi- 
tion. When  moist  sounds  in  the  chest  have  succeeded  to  dry 
rhonchus  or  tubular  breathing,  we  may  commence  the  system  of 
treatment  which  modern  practice  has  sanctioned,  and  give  cod- 

*  Nutrition  in  Health  and  Disease,  1876,  p.  93. 


PULMONARY    CONSUMPTIOX.  521 

liver  oil  and  mild  tonics  during  the  daytime.  In  the  evening, 
when  febrile  symptoms  are  chiefly  observed,  citrate  of  potash  and 
the  alkaline  carbonates  will  abate  the  excitement,  and  soon  enable 
us  to  give  quinine  safely  in  small  or  large  doses  so  as  to  check  the 
febrile  exacerbations.  For  children  I  am  in  the  habit  of  giving  a 
grain  of  quinine  in  powder  half  an  hour  before  going  to  bed,  and 
sponging  the  body  lightly  with  tepid  water,  if  hot  and  dry,  or 
with  cold  water  if  the  temperature  is  disposed  to  rise  rapidly. 

Cod-liver  oil  is  the  most  effectual  remedy  of  all  others  in  the 
management  of  this  disorder,  and  may  be  given  when  febrile  ex- 
citement has  not  departed.  Dr.  Williams  says :  "Cod-liver  oil, 
when  taken  into  the  system  in  sufficient  quantities,  and  for  a 
sufficient  length  of  time,  acts  as  a  nutrient,  not  only  adding  to 
the  fat  of  the  body,  but  also  promoting  the  healthy  growth  of  the 
protoplasm  and  the  tissue-cells,  and  in  some  way,  as  an  alterative, 
counteracting  the  morbid  tendency  to  the  proliferation  of  the 
decaying  cells  of  pus,  tubercle,  and  kindred  cacoplastic  and  aplastic 
matters."* 

When  the  oil  is  pale  and  pure  it  seldom  causes  nausea  or  dis- 
turbs the  functions  of  the  liver.  I  prefer  giving  it  after  a  meal  in 
a  little  orange  wine  or  with  a  small  quantity  of  milk,  which, 
however,  does  not  always  agree.  Dr.  Williams  gives  it  with  a 
mild  acid  or  aromatic  bitter — he  gives  the  nitric,  hydrochloric, 
sulphuric,  or  phosphoric,  according  to  the  special  circumstances  of 
each  case,  and  I  can  speak  most  favorably  of  the  combination.  I 
have  been  in  the  habit  of  giving  the  hydrochloric  acid  before  the 
meal,  and  the  oil  afterwards.  In  weakness  of  the  stomach,  with 
a  tendency  to  retching  and  nausea,  the  o'^th  or  -g'.jd  of  a  grain  of 
strychnia  is  given  by  Dr.  Williams  with  each  dose  of  oil.  But  it 
must  have  come  within  the  experience  of  every  one  that  cod-liver 
oil,  when  long  continued,  is  apt  to  disagree  with  the  stomach,  and  to 
cause  biliary  derangement,  particularly  if  the  diet  is  not  carefully 
regulated.  Here  it  must  be  suspended  "for  a  time,  and  an  alterative 
and  alkaline  treatment  employed  till  digestion  is  restored  to  a 
healthy  state.  In  the  winter  season  of  the  year  cod-liver  oil  is 
an  indispensable  remedy,  and  may  be  continued  for  months 
together.  There  is  a  preparation  called  the  compound  phospho- 
rated cod-liver  oil,t  which  I  have  found  useful  in  the  strumous 

*  Op.  cit.,  1871,  p.  322. 

t  Prepared  by  Savory  and  Moore,  Xew  Bond  Street.  A  fluid  drachm  contains  one 
grain  of  iodine,  two  grains  of  bromine,  and  one-fortieth  of  a  grain  of  phosphorus. 


522  DISEASES   OF   CHILDREN. 

diseases  of  cliilrlren.  But,  however  combined,  tlie  daily  use  of  the 
oil  has  superseded  every  remedy  that  has  hitherto  been  proposed, 
and  there  is  not  a  physician  in  this  country  or  abroad,  who  is  not 
convinced  of  its  efficacy,  both  in  prolonging  life  and  in  curing 
disease. 

The  hypophosphites  of  lime  and  soda,  with  strychnia,  iron,  and 
quinine,  form  an  excellent  combination,  with  which  I  am  well 
satisfied  in  these  cases,  and  in  all  states  of  general  debility  and 
nervous  exhaustion. 

Whilst  we  are  giving  astringents  to  check  diarrhoea,  and  seda 
tives  to  relieve  cough,  we  are  diminishing  the  strength  and  appe- 
tite, and  the  disease  meanwhile  advances.  The  best  means  of 
relieving  these  S3m:iptoms  is  to  increase  the  general  strength,  by 
supplying  the  system  with  fatty  elements  in  a  form  that  can  be 
easily  assimilated.  We  have  found  this  remed}^  in  cod-liver  oil. 
The  molecular  fluid  of  the  chyle  consists  of  fatty  particles,  from 
which  the  blood  and  tissues  of  the  body  are  formed,  and  if  chyli- 
fication  is  imperfect  or  tardy,  the  blood  is  watery  and  albumin- 
ous, and  thus  exudation  is  favored.  Physiology  never  exposed  a 
greater  therapeutic  error  than  when  it  showed  the  danger  of 
treating  low  inflammatory  exudation  by  depressing  the  vital 
powers  so  that  its  molecules  were  incapable  of  passing  through 
those  transformations  which  lead  to  growth  and  elimination.  By 
an  opposite  mode  of  treatment  depraved  nutrition  is  restored,  the 
respiratory  organs  are  stimulated  to  active  exertion,  and  the 
tissues  attract  from  a  better  quality  of  blood  the  necessary  elements 
for  the  support  of  the  body. 

In  the  case  of  an  infant,  if  the  mother  is  delicate,  or  comes  of  a 
consumptive  stock,  and  cannot  suckle  her  child,  a  healthy  nurse 
should  be  procured.  •  Older  children  who  exhibit  a  tendency  to 
tuberculosis  should  wear  flannel  next  the  skin ;  the  diet  should  be 
plain  and  nutritious,  consisting,  of  eggs  and  milk,  and  meat  twice 
a  day  if  the  child  can  digest  it. 

Quinine,  by  improving  the  strength  and  appetite,  and  iron,  by 
altering  the  quality  of  the  blood,  are  two  most  valuable  remedies 
when  the  digestive  functions  have  been  brought  into  a  proper 
state,  and  there  is  no  risk  of  renewing  inflammation  in  the  pul- 
monary organs.  If  there  is  an}'-  degree  of  febrile  excitement  or 
cough,  it  is  preferable  to  omit  the  iron  till  it  is  reilaced,and  direct 
the  treatment  to  special  symptoms.     The  effect  of  quinine  in  non- 


PULMONARY   CONSUMPTION.  523 

tuberculous  cases  is  very  remarkable  in  coutrolling  the  remissions 
and  exacerbations  of  tlie  fever  ;  it  is  the  most  valuable  remedy  we 
possess,  and  in  every  case  of  oscillating  temperature  which  I  have 
treated  it  has  been  followed  by  a  fall.  AVhere  the  fever  has  not 
80  quickly  yielded,  the  lung  has  shown  evidence  of  some  change, 
in  the  shape  of  small  and  localized  pneumonia,  or  gastro-hepatic 
disorder,  or  there  has  been  cause  to  suspect  real  tuberculosis. 
Cod-liver  oil  should  always  be  given  in  the  daytime,  when  the 
temperature  is  normal,  and  quinine  in  the  evening,  before  the  rise 
is  expiected.  The  benefits  derived  from  change  of  air  and  sea- 
bathing are  too  obvious  to  need  illustration. 

When  we  encounter  phthisis  in  the  first  or  incipient  stage,  we 
should  aim  at  improving  the  general  health  by  placing  the  patient 
under  the  most  favorable  circumstances  for  controlling  inflamma- 
tion and  promoting  the  absorption  of  any  tubercle  or  low  organ- 
ized deposit  that  may  have  taken  place.  For  this  purpose,  what- 
ever encourages  local  inflammation  and  congestion,  such  as  cold, 
damp,  and  exposure,  should  be  dealt  with.  Flannel  should  be 
worn  next  the  skin,  and  the  feet  especially  kept  warm.  Conges- 
tion may  be  relieved  by  the  application  night  and  morning  of 
diluted  tincture  of  iodine  (one  in  seven)  to  that  part  of  the  chest 
which  gives  evidence  of  localized  mischief.  When  there  is  bron- 
chial irritation  and  cough,  a  turpentine  liniment,  or  camphor  lini- 
ment containing  croton  oil,  is  one  of  the  best  and  most  serviceable 
applications.  The  remaining  treatment  of  this  stage  consists  in 
p)roviding  the  patient  with  pure  air  and  a  seaside  residence,  if 
possible,  such  as  St.  Leonard's,  Torquay,  Yentnor,  Bournemouth, 
or  Clifton  in  this  country,  or  the  south  of  France  and  the  healthi- 
est parts  of  the  Mediterranean  abroad.  Sponging  with  sea-water, 
followed  by  friction,  will  be  necessary,  and  such  exercise  as  the 
strength  is  equal  to  endure. 

Children  affected  with  consumption  should  not  sleep  with  other 
children  or  occupy  the  same  room  at  night. 

In  phthisis  we  have  to  deal  with  a  low  form  of  cell  growth, 
which  has  a  decided  tendency  to  spread.  Our  energies  then  have 
to  be  directed  to  this  condition,  and  this  essentially  depends  upon 
the  improvement  of  tissue  nutrition,  for  these  two  things  are 
requisite :  first,  the  arrest  of  all  outgoings  which  impoverish  the 
system;  and  second,  to  improve  the  assimilation.  To  attain  the 
first  object  it  is  necessary  to  arrest  the  nightsweats,  and  to  hold 


524  DISEASES   OF    CHILDREN. 

in  check  the  diarrlioea.  Where  both  exist,  sulphate  of  copper  is 
most  useful,  aud  it  is  often  well  to  give  opium  with  it.  AVhere 
there  are  profuse  sweats  without  diarrhoea,  belladonna  is  our  sheet- 
anchor.  According  to  Heidenhain,  belladonna  paralyzes  the 
secretory  nerve-endings  of  the  sudoriparous  glands.  Children 
tolerate  belladonna  much  better  than  adults,  and  no  serious  toxic 
symptoms  need  be  apprehended  from  anything  like  medicinal 
doses.  It  is  well  to  prescribe  belladonna  in  the  form  of  its  active 
agent  atropia.  As  sulphate  of  atropia,  belladonna  can  be  given 
in  precise  doses,  while  it  has  the  great  advantage  of  being  taste- 
less. Children  will  tolerate  doses  commencing  with  gr  -^th  at 
bedtime,  while  doses  of  gr  ^^gth  three  times  a  day  never  give  real 
cause  for  anxiety.  The  failure  of  belladonna  may  usually  be 
traced  to  insufficiency  of  the  dose.  In  the  very  rare  cases  where 
belladonna  fails,  oxide  of  zinc  with  hyoscyamus  may  be  resorted 
to.  Gallic  acid,  quinine,  dilute  sulphuric  acid,  and  the  tincture  of 
perchloride  of  iron  are  all  useful  remedies  to  arrest  night  perspira- 
tion. When  any  of  these  remedies,  and  full  doses  of  belladonna, 
fail  to  arrest  the  nightsweats,  then  it  becomes  necessary  to  sponge 
the  child  over  with  toilet  vinegar,  or  with  warm  vinegar  and  cap- 
sicum (a  teaspoonful  of  cayenne  pepper  to  the  half  pint  of  vinegar 
diluted  with  water)  about  half  an  hour  before  the  usual  time  when 
the  sweats  become  profuse.  The  arrest  of  the  loss  of  blood-salts 
in  the  sweats  usually  leads  to  improvement  in  the  appetite.  The 
next  point  then  is  to  improve  the  assimilative  process.  It  is  use- 
less to  give  tonics  and  heematics  as  long  as  the  digestion  is  out  of 
order.  If  the  tongue  be  foul,  an  occasional  dose  of  calomel  at 
bedtime,  with  a  little  phosphoric  acid  and  a  vegetable  bitter  three 
times  a  day,  is  indicated.  When  the  tongue  is  raw  or  bare,  or 
denuded  of  epithelium,  bismuth  with  a  little  alkali  is  called  for. 
When  the  appetite  has  returned  and  the  digestive  organs  are  fairly 
working,  then,  and  not  till  then,  tonics  and  haematics  may  be  pre- 
scribed. 

Dr.  McCall  Anderson  has  recorded  two  interesting  cases  of  acute 
phthisis  in  young  subjects,  which  3delded  to  the  treatment  em- 
ployed, the  temperature  falling  in  both  instances  from  105°  to  the 
normal  point  in  the  course  of  a  few  days;  the  copious  rules  dis- 
appearing, the  appetite  returning,  and  loss  of  flesh  and  strength 
being  rapidly  regained.  To  control  the  high  fever  he  applied  to 
the  abdomen  folded  pieces  of  flannel  wrung  out  of  iced  water  for 


PULMONARY   CONSUMPTION.  525 

half  an  hoar  at  a  time,  and  gave  quinine,  opium,  and  digitalis 
internally.  For  the  profuse  perspiration  he  had  recourse  to  the 
subcutaneous  injection  of  gr.  y^„th  of  sulphate  of  atropia  every 
night,  which  entirel}'  arrested  it  after  the  second  night.  When 
the  injection  was  omitted  the  swelling  returned,  and  again  sub- 
sided on  resuming  it.  Nourishment  in  the  shape  of  brandj^,  soup, 
and  iced  milk  were  given  every  hour.- 

In  the  shape  of  medicines  we  must  be  guided  in  a  great  measure 
by  the  pulmonary  condition.  If  it  is  tolerably  quiescent,  the  syrup 
of  the  iodide  of  iron,  the  syrup  of  phosphate  of  iron,  and  the 
mineral  acids  will  be  demanded.  Cod-liver  oil  or  malt  extract  if 
there  is  wasting.  When  the  disease  has  passed  into  the  second 
stage  or  that  of  suppuration,  we  must  employ  such  remedies  as 
relieve  cough  and  facilitate  expectoration.  If  the  patient  is  very 
weak,  and  the  lung  has  broken  down,  the  accumulation  of  matter 
in  a  cavity  is  attended  with  most  distressing  symptoms, — weight 
and  pain  in  the  chest,  gasping  respiration,  incessant  cough,  wander- 
ing, sleeplessness,  and  excitement. 

The  inhalation  of  carbolic  acid  by  means  of  the  spray  (1  in  40) 
■will  sometimes  relieve  this,  but  it  often  fails,  and  then  it  is  neces-  • 
sary  to  resort  to  an  emetic  of  sulphate  of  zinc, — about  ten  grains 
in  a  tablespoonful  of  water,  followed  by  a  little  warm  water,  will 
eft'ect  this  purpose.  In  a  girl  14  years  of  age,  under  my  care  in 
1869,  vidth  a  large  cavity  in  the  upper  lobe  of  the  left  lung,  I 
found  this  act  remarkably  well.  It  never  occasioned  hfemoptysis, 
of  which  there  is  a  dread,  but  enabled  the  poor  child  to  throw  ojff 
a  large  quantity  of  pus  from  her  chest,  followed  by  great  comfort 
and  relief  in  breathing. 

Cough  is  a  prominent  symptom  of  phthisis,  which  always  calls 
for  attention.  If  it  is  loose  and  moderate,  and  the  child  can  ob- 
tain a  fair  amount  of  rest,  special  remedies  to  check  it  are  hardly 
needed  ;  if  given  tliey  are  apt  to  impair  the  apptetite,  to  derange 
digestion,  and  to  lock  up  secretion.  There  are  similar  drawbacks 
to  bromide  of  p)otassium,  though  to  a  less  extent,  but  if  the  child 
is  kept  awake  at  night  it  becomes  exhausted,  and  then  the  simplest 
remedies  should  be  .first  tried,  as  poppy  and  squill.f    If  the  cough 

*  On  Acute  Phthisis  (Galloping  Consumption),  The  Lancet,  1877,  vol.  i,  pp.  413-415. 
f  Formula  74 : 

K-  Syr.  papav., 
Syr.  scillse, 

Syr.  limonum,  aa ^ss. — M, 

3j  pi'o  re  nata.     Intended  for  cliildren  from  five  to  ten  years  old. 


526  DISEASES    OF    CHIEDREX, 

is  hard  and  violent,  with  scarcely  any  expectoration,  and  there  is 
vomiting  also,  morphia  and  hydrocyanic  acid  may  be  needed  ;* 
vehen  it  comes  on  in  convulsive  paroxysms,  belladonna,  stramonium, 
etc.  If  the  tongue  is  furred,  the  throat  irritable,  and  there  is  any 
amount  of  bronchitis,  chlorate  of  potash,  with  syrup  of  tolu  and 
morphia  may  be  required,f  and  if  the  expectoration  is  difficult, 
ipecacuanha  or  squill  may  be  given,  according  to  circumstances.:}: 
Where  there  is  great  sleeplessness,  hj^drate  of  chloral,  with  bro- 
mide of  potassium  in  syrup  of  tolu  or  squill,  may  sometimes  be 
given  with  advantage.  Where  the  respiration  is  accelerated  be- 
cause the  lung-space  is  infringed  upon,  the  administration  of  dis- 
tinctly depressing  remedies  is  fraught  with  danger  of  paralyzing 
the  respiratory  efforts. 

In  the  treatment  of  hmmo'ptysis  we  must  be  guided  by  the  amount 
of  blood  lost.  If  small  in  quantity,  perfect  rest  should  be  main- 
tained, ice  to  suck,  and  the  avoidance  of  all  stimulants  may  be 
enough  to  check  it,  but  if  there  be  any  considerable  loss,  and  the 
lung  is  breaking  down,  or  there  is  a  cavity,  some  styptic  remedy 
must  be  employed  at  regular  intervals.  Dr.  C.  J.  B.  Williams 
speaks  highly  of  gallic  acid  with  acid  tartrate  of  potash.  Tannic 
acid  and  gallic  acid  combined,  acetate  of  lead,  ergot,  and  tincture 
of  perchloride  ®f  iron  are  all  useful  in  special  cases.  The  diet 
should  consist  of  milk,  cold  beef  tea,  broth,  etc.     It  is  important 

*  Formula  75 : 

K.  Morpli.  acet., gr-  i 

Acid,  hydrocy.  dil., ♦tK^vj 

Glycei'ini,         .........     ^ij 

Aquam  ad         ........         .     ^^iss. — M. 

3J  pro  re  nata. 
t  Formula  76 : 

R.  Potass,  clilorat.,       . ^ss. 

Liquor,  morph.  hydroclilor., 

Syr.  tolutani,  . 

Aquam  ad       .         .         . 

OJ  pro 
X  Formula  77 : 

R.  Liquor,  morph.  liydrochlor., i^i^xx 

Vin.  ipecac,   . ,      .         •     3J 

Oxymellis  scilla?, 

Syr.  mori,  aa  .         .         .         .         ;         .         .         .         .     gss. 

Mist,  acaciae  ad 3ij. — M. 

3j  pro  re  nata. 
These  prescriptions  are  intended  for  eliildren  from  five  to  ten  years  old. 


ti^xx 

3vj 

5iJ--M. 

e  nata. 


PULMONARY   CONSUMPTION.  627 

to  keep  the  bowels  well  open,  and  for  this  purpose  sulphate  of  mag- 
nesia and  sulphuric  acid,  in  infusion  of  roses,  is  a  good  formula. 
When  the  haemoptysis  has  ceased,  cod-liver  oil  and  other  tonics  can 
be  resumed. 

Diarrhcea  is  another  complication  of  phthisis  tending  to  produce 
great  exhaustion  and  emaciation.  When  persistent  it  may  depend 
upon  ulceration  of  the  small  intestine.  It  is  a  symptom  that  must 
be  combated  at  once  by  remedies  of  a  suitable  character.  If  the 
tongue  is  coated,  and  there  is  impaired  digestion  or  unhealthy 
fffices,  a  few  grains  of  gray  powder  with  rhubarb  will  be  needed, 
and  when  the  secretions  are  corrected,  one  of  the  diarrhoea  for- 
mulae will  be  useful.*  Those  containing  bismuth,  logwood,  kra- 
meria,  sulphate  of  copper  and  opium,  acetate  of  lead,  etc.,  are  the 
best.  Opiate  enemata  must  be  had  recourse  to  in  severe  cases,  and 
fomentation  and  poultices  may  be  required  if  there  is  abdominal 
pain  and  tenderness.  The  diet  should  consist  of  rice,  milk,  arrow- 
root, etc. 

The  hypophosphites  of  lime  and  soda  are  highly  spoken  of  by 
some  authorities.  They  are  especially  recommended  by  Dr.  Thorow- 
good.  In  many  cases  under  his  care  "  decided  and  unmistakable 
good  came  of  their  administration,  and  that  too  when  other  well- 
devised  means  of  cure  had  proved  useless. "f  He  gives  instances 
in  which  "  nightsweats "  and  fever  gradually  disappeared,  and 
moist  sounds  in  the  lungs  ceased  under  their  administration.  In 
a  few  cases  cavities  contracted  and  became  drier.  Some  of  the 
patients  when  seen  months  afterwards  appeared  well.  Dr.  Thorow- 
good  advises  the  hypophospite  of  soda  when  there  is  a  tendency  to 
gastric  irritation,  and  the  lime-salt  in  cases  of  diarrhoea.  To  the 
former  a  few  grains  of  bicarbonate  of  soda  may  often  be  advan- 
tageously added.  Where  there  is  slight  congestion  at  the  apex  of 
the  lung,  and  there  is  crackling  or  clicking,  it  may  be  used,  but  if 
dyspepsia  or  bronchitis  from  recent  cold  is  present,  it  should  be 
temporarily  exchanged  for  other  remedies.  In  the  early  or  in- 
cipient stage,  when  there  is  localized  dulness,  with  harsh  or  tubular 
breathing,  or  even  when  crackling  announces  that  the  lung  is  con- 
gested or  giving  waiy,he  has  found  them  of  great  value.  lie  gives 
the  hypophosphite  of  soda  or  lime,  in  infusion  of  calumba,  three 

*  See  Chap.  XV,  On  Diarrlicea. 

f  On  Consnmjjtion  and  its  Treatment  by  the  Hj'pophosphites,  3d  edit.,  1880. 


528  DISEASES   OF   CHILDREN. 

times  a  day.*  It  may  be  combined  with  barkf  or  some  of  tbe 
preparations  of  iron.:}:  The  hypopliosphites  are  well  spoken  of  in 
combination  with  cod-liver  oil,  phosphoric  acid,  quinine  and  glyc- 
erin by  Dr.  C.  J.  B.  Williams. §  "  Of  all  the  tonics  for  strength- 
ening the  stomach  and  preventing  nansea,  with  the  oil,  strj^chnia 
is  by  far  the  best ;  and  as  it  has  no  heating  property,  its  addition 
to  the  compound  orange  infusion  snpplies  the  most  elegant  and 
effectual  form  of  oil-sauce  that  I  have  yet  devised."||  I  have  long 
been  in  the  habit  of  prescribing  strychnia  in  these  cases  with  the 
best  advantage. 

*  FormuLa  78  : 

R.  Sodfe  hypophosphitis, 3ss. 

Syr.  anrant., ^iij 

Inf.  calumbae  ad ^vj. — M. 

A  tablespoonful  three  times  a  day.     For  children  ten  years  of  age  and  upwards. 

f  Formula  79  : 

R.  Sodse  hypophosphitis, ^ss. 

Syrupi, ^iij 

Inf  cinch,  flav.  ad 5vj. — M. 

A  tablespoonful  to  be  taken  three  times  a  day.     For  children  ten  years  of  age  and 
upwards. 

X  Formula  80 : 

R .  Tinct.  ferri  perchl., 5j 

Calcis  hypophosphitis, gss. 

Glycerini, ^iij 

Aquam  ad ^vj. — M. 

A  tablespoonful  three  times  a  day.     For  children  ten  years  of  age  and  upw,ards. 
§  Formula  81 : 

R.  Sodse  hypophosphitis, ^ss. 

Acid,  phosph.  dil., gij 

Tinct.  quiniae, 

Glycerini  aa ^ss. 

Inf.  aurant  co.  ad       .         .         .         .         .         .         .         .     ^vj. — M. 

A  tablespoonful  three  times  a  day,  with  one  teaspoonful  of  cod-liver  oil.   For  children 
ten  years  of  age  and  upwards. 

II  Pulmonary  Consumption,  by  C.  J.  B.  and  C.  Theodore  Williams,  M.D.,  1871, 
p.  359. 


DISEASES    OF    THE    HEART.  529 

CHAPTER  XLL 

DISEASES   OF    THE    HEART. 

Functional  Diseases  of  the  Hkart.  Palpitation.  Definition  and  Symp- 
toms :  Causes — Graves's  disease — Chorea,  Syncope  or  Fainting.  Neurosal 
Affections  :   Causes,  symptoms,  and  treatment. 

Organic  or  Structural  Diseases  of  the  Heart.  Pericarditis  :  Two  varieties 
described — Acute  and  chronic — Symptoms,  general  and  physical — Delirium — Mode  of 
iermination — Diagnosis  and  jj^'ognosis — Morbid  anatomy.  Causes:  Acute  rheuma- 
tism—  Extension  of  pneumonia  or  pleurisy  —  Renal  disease — Chorea — Scarlatina. 
Treatment  :  Local  and  generai  means — Venesection — Leeching — Blisters — Mercury 
— Opium— Stimulants.  Chronic  Pericarditis:  Causes — Symptoms — Consequences 
— Treatment.  Hy^drgpericardium  :  Active  and  passive — Local  and  constitutional 
signs — Treatment  by  purgatives — Diuretics  and  tapping.  Endocarditis.  Causes  : 
Acute  rheumatism — Scarlet  fever — Bright's  disease.  Symptoms  and  Diagnosis: 
Belation  to  pericarditis — Pathologiccd  changes — Liability  to  terminate  in  valvular  dis- 
ease and  embolism.  Treatment  :  Importance  of  ascertaining  the  cause  and  regulating 
the  treatment  accordingly — Perfect  rest  in  bed  to  lower  blood-pressure  and  excitement  of 
the  circviaiiovL —  Use  of  hydrate  of  chloral.  Myocarditis  :  Occurs  sometimes  with 
endocarditis,  scarlet  fever ^  and  typhoid  fever.  Ulcerative  Endocarditis  (Kirke). 
Diphtheritic  Endocarditis  (Rosenstein).  Infecting  Endocarditis  (Cayley) : 
Pathology — Diagnosis — Causes  and  treatment. 

Valvular  Disease  of  the  Heart  :  General  symptoms  of — Disease  of  the  aortic  valves 
— Aortic  regurgitation — Disease  of  the  right  auricido-ventricular  orifice — Tricuspid  regur- 
gitation—  General  and  physical  signs — Venous  pulsation — Liability  to  ana.mrca  and 
dropsy — Disease  of  the  pulmonary  valves  (Peacock) — Disease  of  the  left  auriculo-ventric- 
ular  orifice  {mitral  regurgitation)  —  Chiefly  in  girls — Symptoms  and  consequences  of 
mitral  disease — Congestion  of  lungs  in — Character  of  the  pulse — Obstructive  disease 
(narrowing)  of  mitral  orifice  [mitral  stenosis),  state  of  the  pulmonary  circulation — Pre- 
systolic murmur — How  produced  and  its  importance  as  a  diagnostic  sign — Pathological 
anatomy  of  the  diseased  orifices  and.  valves — Common  causes  of  valvular  disease,  especially 
rheumatism — General  treatment  and  management — Effects  of  digitalis  in — Iron — 
Strychnia — Association  with  rickets  (Kokitansky,  Hilton  Fagge),  distortion  of  thorax — 
Heart  cough.  Hypertrophy  and  Dilatation  :  Causes  due  to  obstructed  circula- 
tion— General  and  physical  sign^ — Character  of  apex-beat  and  pulse — Area  of  cardiac 
dulness  increased;  masked  by  emphysematous  lung — Hypertrophy  of  right  ventricle  and 
dilatation — Epigastric  pulsation — Hypertrophy  and  dilatation  from  chronic  kidney 
disease — Treatment.  Perforation  of  the  Interventricular  Septum  (Nie- 
meyer).  Defective  Closure  of  the  Foramen  Ovale.  Pulmonary'  Ste- 
nosis. Cyanosis.  (Morbus  C^rl'leus,  Blue  Disease)  :  Symptoms — Causes 
and  treatment. 

In  children,  owing  to  the  thinness  of  the  chest-walls,  the  im- 
pulse of  the  heart  is  diffused  over  a  larger  space  than  in  adults ; 
not  unfrequently  a  part  of  the  right  ventricle  may  be  detected 
beating  immediately  under  the  left  costal  cartilages,  close  to  the 
sternum.     The  apex  may  also  be  seen,  as  well  as  felt,  in  the  nor- 

34 


530  DISEASES   OF   CHILDREN. 

mal  position.  When  the  intercostal  spaces  are  depressed,  and  the 
ribs  prominent  at  their  attachment  to  the  sternum,  the  partial 
outHne  of  the  heart  becomes  all  the  more  distinct.  The  shape  of 
the  chest,  whether  natural,  rickety,  or  pigeon-breasted,  will  influ- 
ence the  area  of  percussion  dulness,  and  the  extent  of  the  cardiac 
movement  perceptible  beneath  the  thoracic  parietes. 

The  size  of  the  heart  does  not  increase  with  absolute  regularity 
in  childhood,  for  Rilliet  and  Barthez  have  shown  that  between 
the  age  of  fifteen  months  and  five  years  and  a  half,  its  circum- 
ference remains  nearly  the  same,  increasing  slowly  afterwards 
until  puberty. 

FuNCTiOjjiTAL  Disease  oe  the  Heart. 

Palpitation. — We  understand  by  palpitation  a  frequent  and  tu- 
multuous action  of  the  heart,  not  usually  accompanied  by  organic 
disease,  though  it  is  sometimes  present  in  valvular  afiections.  On 
placing  the  hand  over  the  cardiac  region,  a  sudden  and  violent 
thumping  movement  is  appreciable,  and  the  heart's  action  can  be 
seen  beneath  the  chest-walls.  The  sounds  are  exaggerated,  and 
there  is  sometimes  a  soft  bruit  which  vanishes  when  the  organ  re- 
sumes its  ordinary  tranquillity.  When  the  disorder  is  well  pro- 
nounced, there  is  considerable  constitutional  excitement,  quick 
pulse,  headache,  and  a  tendency  to  sj'ncope.  The  female  sex  is 
more  liable  to  it  than  the  male.  As  growth  proceeds,  and  the 
health  remains  delicate,  continued  palpitation  of  the  heart  may 
induce  hypertrophy  or  dilatation. 

The  causes  of  this  functional  disorder  are  the  nervous  tempera- 
ment, running  after  meals,  violent  exercise,  mental  emotion,  anger, 
fear,  etc.  It  is  often  witnessed  among  choreic  children,  and  those 
reduced  by  chronic  or  lingering  disease,  loss  of  blood,  dyspepsia, 
and  pulmonary  affections.  In  Graves's  disease  (exophthalmia)  the 
anaemic  condition  is  accompanied  by  palpitation  of  the  heart  and 
throbbing  of  the  arteries. 

The  diagnosis  mainl}^  rests  on  the  absence  of  the  signs  of  organic 
disease  and  the  frequency  of  the  pulse,  followed  by  steadiness  and 
regularity  as  the  attack  subsides. 

The  treatment  consists  in  the  removal  of  the  cause,  if  this  can 
be  done,  and  the  improvement  of  the  digestive  and  nervous  func- 
tions. Where  there  is  dyspepsia,  an  alkali  with  hydrocyanic 
acid  will  calm  the  excitement,  and  afterwards  the  ammonio-cit- 


DISEASES    OF    THE    HEART.  531  ' 

rate  of  iron,  with  a  drop  or  two  of  liquor  strjchnife,  according  to 
age,  may  be  given  with  advantage.  The  eniplastrura  belladonnse 
may  be  applied  over  the  cardiac  region  if  there  be  pain  there. 
When  the  symptoms  persist,  the  main  hope  of  relief  depends  on 
an  improved  state  of  the  blood  and  attention  to  hygienic  rules. 

Syncope  or  fainting  is  occasionally  observed  in  children  of  ner- 
vous constitution.  A  peculiar  sensation  is  first  experienced  of 
dizziness  and  swimming  before  the  eyes,  and  singing  noises  in  the 
ears.  Then  the  face  and  lips  become  pale,  the  skin  clammy,  and 
the  pulse  at  the  wrist  so  weak  that  it  is  barely  perceptible.  The 
patient  if  unsupported  falls  to  the  ground,  and  the  breathing  is 
hardly  distinguishable.  This  alarms  friends  and  bystanders,  for 
the  pallor  of  the  face  is  deathlike,  the  muscles  are  relaxed,  and 
the  extremities  are  cold.  By-and-by,  if  the  recumbent  posture  is 
maintained,  a  few  deep  sighs  are  drawn,  and  as  respiration  is 
established  the  natural  color  of  the  face  returns.  Mild  cases  do 
not  last  over  a  few  seconds  and  the  pulse  is  only  slow  and  weak; 
but  severe  cases  continue  for  some  minutes,  and  the  patient  no 
sooner  shows  signs  of  rallying  than,  in  attempting  to  stand  up,, 
the  syncope  returns  at  once,  the  eyelids  quiver,  and  drops  of  sweat 
stand  upon  the  forehead. 

The  causes  are  loss  of  blood,  or  even  the  sight  of  it  in  some 
nervous  constitutions,  profuse  diarrhoea-,  extreme  fatigue,  severe 
pain,  and  affections  of  the  heart.  Sudden  shock,  or  even  excite- 
ment, are  also  capable  of  producing  the  symptoms. 

Ti^eatment. — The  recumbent  posture  should  be  maintained,  and 
a  current  of  fresh  air  be  admitted ;  ammonia  to  the  nostrils, 
sprinkling  cold  water  over  the  face,  loosening  all  dress,  and  fric- 
tion of  the  limbs.  When  the  patient  can  swallow,  a  little  brandy 
and  water,  or  a  draught  containing  ammonia  with  spirit  of  chlo- 
roform, should  be  given.  If  the  vapor  of  ammonia  be  applied  to 
the  nostrils,  it  should  be  done  with  care. 

Neurosal  Affections. — These  consist  of  a  neurosis  of  the  cardiac 
ganglia,  inducing  functional  disturbance  in  the  heart's  action. 
This  neurosis  is,  I  believe,  a  very  common  disorder  among  deli- 
cate children.  When  they  cry  on  slight  provocation,  and  are 
restless  and  excitable,  a  careful  examination  of  the  heart  and  cir- 
culation will  often  throw  light  upon  an  obscure  set  of  symptoms. 
I  have  elsewhere  fully  entered  into  this  subject.*     The  complaint 

"■^  Nenrosal  Affections  of  the  Heart  in  Children,  Practitioner,  Sept.,  1878. 


532  DISEASES    OF    CHILDEEX. 

is  observed  in  weak  and  delicate  children,  and  in  those  who  suffer 
from  chorea  or  nervous  states  resembling  it.  Children  who  are 
born  prematurely,  and  who  are  badly  reared  and  neglected  during 
the  first  year  of  life,  are  liable  to  it  as  they  approach  seven  or 
eight  years  of  age,  particularly  if  the  strain  of  school  life  is  put 
upon  them  too  early.  General  debility  from  any  cause,  such  as 
anaemia  and  loss  of  blood,  by  disturbing  the  equanimity  of  the 
nervous  system,  will  cause  perverted  nerve  action.  It  may  follow 
whooping-cough,  chronic  enlargement  of  the  tonsils,  or  chronic 
pneumonia.  The  offspring  of  nervous  or  insane  parents  are  also 
subject  to  it. 

The  symptoms  are,  palpitation  of  the  heart,  followed  by  faintness 
and  exhaustion.  If  the  hand  be  placed  over  the  cardiac  region,  a 
thumping,  violent  movement  is  communicated  to  it,  accompanied 
by  irregularity  or  intermission  of  the  pulse.  This  sj-mptom  is 
always  a  sign  of  imperfect  muscular  action  through  the  quality  of 
the  blood  and  the  unstable  condition  of  the  nervous  system.  Sleep 
is  unrefreshing,  and  restless  or  noisy  ;  dreaming  is  common  ;  and 
the  urine  often  contains  phosphates. 

The  treatment  which  1  have  almost  invariably  found  successful 
consists  in  the  employment  of  rest  and  tonics,  good  food,  cod-liver 
oil,  and  warm  clothing.  Steel  wine  and  arsenic  (Form.  93), 
quinine,  the  syrup  of  phosphate  of  iron,  the  ferrum  dialysatura 
(dialyzed  iron),  and  Parrish's  chemical  food,  are  valuable  remedies 
in  particular  cases  ;  but  I  place  the  greatest  confidence  in  a  com- 
bination of  iron,  digitalis,  and  strychnia.  If  there  is  excitement, 
and  sleep  cannot  be  obtained,  iron  may  be  combined  with  the 
bromide  of  potassium. 

Organic  or  Structural  Diseases  of  the  Heart. 

Pericarditis. — Two  varieties  of  pericarditis  are  commonly  de- 
scribed, the  acute  and  chronic.  Inflammation  of  the  pericardium 
<3onsists  in  the  first  instance  of  distension  of  the  capillaries,  and 
secondly  of  effusion  of  serum  or  lymph  exuding  from  them ;  and 
in  some  cases,  as  absorption  of  the  fluid  proceeds,  it  ends  in  the 
gluing  of  the  two  surfaces  of  the  pericardium  together.  The 
character  of  the  exudation  is  in  a  great  measure  dependent  upon 
the  constitutional  condition  of  the  patient. 

The  general  symptoms  of  acute  pericarditis  are  more  or  less  pain 
in  the  precordial  region  at  the  situation  of  the  apex,  or  at  the 


DISEASES    OP   THE    HEART.  533 

lower  end  of  tlie  sternum;  it  may  strike  through  the  thorax  to 
the  scapula,  or  extend  down  the  left  arm  to  the  elbow  and  wrist. 
The  pain  in  most  acute  cases  is  of  a  sharp,  lancinating  character, 
and  is  aggravated  at  each  shallow  inspiration,  or  movement  of 
the  patient.  He  cannot  turn  on  his  side,  or  bear  the  slightest 
pressure  over  the  thorax;  even  the  weight  of  the  bedclothes  is 
oppressive.  The  pain  in  pericarditis,  when  accompanied  by  articu- 
lar rheumatism,  may  be  owing  to  an  affection  of  the  muscles;  and 
in  one  case  which  came  under  my  care,  where  the  physical  signs 
were  not  conclusive,  the  cervical  muscles  were  considerably  impli- 
cated, and  the  patient  could  not  move  his  head  from  side  to  side 
in  the  slightest  degree.*  Sometimes  the  pain  is  of  a  dull,  aching, 
continuous  character,  or  it  is  too  slight  to  attract  notice  ;  in  many 
instances  it  is  absent  altogether,  and  the  physician  might  overlook 
pericardial  mischief,  if  the  anxious  and  alarmed  expression  of  the 
patient  did  not  invite  a  close  inspection  of  the  thoracic  contents. 
This  anxiety  of  expression,  moreover,  is  frequently  noticeable 
before  there  are  any  reliable  physical  signs  to  indicate  a  lesion  in 
the  pericardium.  Palpitation  and  irregular  action  of  the  heart 
are  by  no  means  infrequently  added  to  the  pain  as  the  disease 
proceeds. 

Pleurisy  is  sometimes  associated  with  pericarditis,  and  may 
even  originate  the  latter  afl'ection  by  extension. f  Endocarditis  is 
frequently  present,  the  two  diseases  being  in  close  relationship 
with  one  another,  and  arising  from  precisely  the  same  causes. 

Pericarditis  sometimes  commences  with  rigors  succeeded  by 
fever,  and  a  full,  hard,  and  frequent  pulse, — in  some  cases  it  is 
small,  unequal,  or  irregular.  As  effusion  takes  place  there  are 
dyspnoea,  hurried  respiration,  great  restlessness,  and  insomnia. 
The  commencement  of  the  disorder  may  be  marked  by  heat  of 
skin,  but  this  is  soon  bathed  in  perspiration,  and  the  face  becomes 

*  "  But  pain  is  far  from  being  a  constant  indication  of  pericarditis,  and  M.  Boiiilland 
has  found  it  so  often  absent,  that  he  attributes  it,  wlien  present,  to  the  coexistence  of 
plenrisv,  and  Dr.  Hope,  although  he  does  not  agree  with  M.  Bouilhiud  in  this  opinion, 
yet  states  as  the  result  of  his  extensive  experience,  that  in  the  great  majority  of  oases 
of  pericarditis  the  pain  was  either  whoUv  absent,  or  was  of  a  mild  and  endurable 
kind." — Semple,  On  Diseases  of  the  Heart,  1876,  p.  140. 

t  Dr.  Sibson  ascertained  that  in  31  out  of  63  cases  there  was  pain  in  the  side ;  in 
19  cases  on  the  left  side,  to  the  right  in  5,  and  in  both  sides  in  6.  In  15  out  of  the  31 
cases  a  pleuritic  friction-sound  was  heard  in  tlie  side.  On  Pericarditis,  Eeynolds's 
System  of  Medicine,  vol.  iv,  p.  232. 


534  DISEASES    OF    CHILDREJJi. 

pinched  and  intensely  anxious.  In  young  children  there  may  be 
early  convulsions,  and  as  exhaustion  proceeds,  and  the  circulation 
is  more  embarrassed,  there  is  delirium,  and  abrupt  sleep  disturbed 
by  dreams.  In  severe  cases,  the  child  has  the  expression  of  alarm 
and  dread,  he  cannot  lie  easy  in  any  position,  and  is  afraid  of  being 
examined  or  approached.  When  the  disease  is  about  to  terminate 
fatally  clammy  sweats  break  out,  the  face  becomes  livid,  and  the 
eyes  are  staring  and  glassy. 

The  characteristic  auscultatory  sign  which  renders  the  diagnosis 
unmistakable  is  a  to-and-fro  sound  (hrult  de  frottement).  This  is 
the  earliest  sign  of  pericarditis,  which  cannot  be  discovered  unless 
the  friction-sound  is  produced.  (The  late  Dr.  Hj-de  Salter,  and 
Dr.  George  Johnson,  of  King's  College  Hospital,  insist  that  the 
friction-sound  is  triple  "  rub-a-dub  dubb."  There  is  first  the 
auricular  contraction,  then  the  contraction  of  the  ventricle,  and 
lastly  the  dilatation  of  the  ventricle  in  diastole.)  This  sound 
depends  on  the  position  of  the  exudation ;  if  it  cover  the  auricle 
there  is  decidedly  auricular  friction,  such  as  Dr.  Johnson  has 
described  ;  if  the  lymph  cover  the  ventricle  only,  the  sound  -is 
simply  to-and-fro.  This  sound  is  caused  hy  the  rubbing  together 
of  the  inflamed  surfaces  of  the  pericardium,  and  a  very  good  imita- 
tion of  it  may  be  obtained  by  applying  one  end  of  a  stethoscope 
against  the  ear,  and  the  other  against  the  palm  of  the  hand.  The 
forefinger  of  one' hand  is  then  rubbed  backwards  and  forwards 
across  the  hand  so  applied,  when  the  peculiar  friction-sound  will 
be  transmitted  through  the  stethoscope  to  the  ear.  The  murmur 
caused  by  the  attrition  of  the  inflamed  surface  of  the  heart  and 
pericardium  closely  resembles  this.  It  varies  necessarily  in  char- 
acter and  intensity  according  to  the  consistence  of  the  eftused 
lympli ;  if  moderately  thick  it  has  a  creaking  character,  like  new 
leather  [bruit  de  cuir),  or  a  rasp-file-like  sound  {bruit  de  rape). 
When  eft'usion  takes  place  to  such  an  extent  that  the  two  surfaces 
do  not  approximate,  the  murmur  is  generally,  though  not  invari- 
ably, lost,  and  the  heart's  sounds  are  distant  or  muffled.  When  the 
friction-murmur  and  the  cardiac  sounds  both  disappear,  we  may 
expect  that  the  quantity  of  exudation  is  considerable.  Important 
as  this  murmur  is  in  a  diagnostic  point  of  view,  we  should  err 
greatly  if  we  supposed  that  its  presence  was  necessary  to  the  ex- 
istence of  pericarditis,  for  a  large  eftusion  n)ay  have  taken  place 
at  a  very  early  stage  of  the  disease,  and  the  sound  will  be  absent 


DISEASES   OF   THE   HEART.  535 

till  the  effusion  lias  become  partially  absorbed.  The  absence  of  the 
murmur  altogether  is  quite  compatible  with  severe  inHammatiou 
of  the  pericardium.  An  endocardial  murmur  is  also  frequently 
heard  (proving  the  implication  of  the  endocardium)  in  the  space 
midway  between  the  left  nipple  and  the  sternum,  which  soon 
extends  over  the  whole  prsecordial  region.  The  exocardial  murmur 
is  distingaished  by  the  superticial  character  of  the  sound,  and  by 
its  limitation  to  the  cardiac  region,  as  well  as  by  its  change  of 
character,  and  its  temporary  disappearance  when  the  effusion  is 
great.  If  the  effusion  is  purely  liquid  it  may  be  absorbed,  but  if 
it  be  more  fibrinous  and  solid,  the  pericardium  is  thickened,  and 
the  opposed  surfaces  may  become  adherent.  AVhen  exudation  has 
taken  place,  the  physical  signs  of  pericarditis  are  increased  dulness 
over  the  prseeordial  region,  according  to  the  extent  of  the  effusion, 
or  ratlier  the  area  of  diminished  resonance  is  not  increased,  unless 
the  effusion  is  considerable.  The  percussion  dulness  occurs  chiefly 
at  the  base  of  the  heart,  where  the  pericardium  is  loose  and  most 
easily  distensible.  It  may  extend  upwards  to  the  second  rib,  and 
transversely  from  the  right  side  of  the  sternum  to  the  line  of  the 
left  nipple.  When  the  pericardial  sac  is  distended  to  any  extent 
the  cardiac  apex  is  pushed  upwards  and  outwards.  In  the  case 
of  a  boy,  7  years  of  age,  with  endocarditis  and  pericardial  effusion, 
the  apex-beat  was  in  the  fourth  interspace,  an  inch  and  a  half 
external  to  the  nipple-line,  and  the  endocardial  murmur  was  very 
loud  towards  the  left  axillary  region.  In  cases  of  this  kind  the 
heart's  sounds  are  often  feeble,  distant,  and  indistinct. 

Pericarditis  may  terminate  in  complete  restoration  to  health 
where  the  eftusion  is  serous  and  watery ;  but  if  lymph  or  solid 
fibrinous  matter  is  thrown  out  into  the  pericardial  sac  it  is  likely 
to  end  in  adhesion  of  the  opposed  surfaces,  and  lead  to  those 
general  and  physical  signs  recognized  under  the  name  of  chronic 
'pericarditis.     It  is  often  accompanied  by  endocarditis. 

Diagnosis  and  Prognosis. — The  diagnosis  is  easy  enough  if  the 
case  is  well  marked,  and  the  effusion  is  serous  and  moderate  in 
quantity.  In  such  cases  as  these  the  patient  may  make  a  com- 
plete recovery,  and  be  none  the  worse  for  the  seizure.  If  the 
effusion  is  thick  and  fibrinous,  as  we  have  just  seen,  it  may  cause 
roughening,  or  adhesion  of  the  surfaces.  Delirium  is  an  important 
diagnostic  symptom,  and  when  it  occurs  early  in  the  disease  it 
may  lead  to  the  false  impression  that  the  brain  is  the  seat. of  the 


536  DISEASES   OF   CHILDREN. 

malady.  "When  delirium  supervenes  in  the  course  of  rheumatic 
fever,  it  would  be  a  culpable  error  not  to  investigate  the  condi- 
tion of  the  heart  carefully  at  every  visit,  exposing  the  patient, 
however,  as  little  as  possible.  Orthopnoea  is  also  an  important 
diagnostic  sign.  The  disease  is  very  fatal  in  weak  and  strumous 
children. 

Morbid  Anatoyny. — There  is  an  effusion  of  serum,  sometimes  of 
a  transparent  lemon-color,  or  of  a  reddish  tinge,  or  there  is  pus 
in  the  pericardium  with  coagulable  lymph,  and  adhesion  between 
the  two  membranes.  The  two  surfaces,  when  torn  asunder  at  this 
stage,  present  a  honeycombed  or  tripelike  appearance.  The  white 
spots,  so  commonly  found  on  the  surface  of  the  heart  after  death, 
have  been  shown  by  Sir  James  Paget  to  arise  from  previous  in- 
flammation. 

Causes. — As  an  idiopathic  affection,  acute  pericarditis  is  ex- 
tremely rare,  yet  it  does  now  and  then  occur,  and  may  escape  de- 
tection in  the  absence  of  pain  about  the  heart ;  as  an  accompani- 
ment of  acute-  rheumatism  it  is  verj^  common.  "  In  5  cases  of 
pericarditis,  in  2  of  acute,  and  in  4  of  chronic  endocarditis,  and  in 
2  more  in  which  both  the  pericardium  and  endocardium  were  in- 
volved— making  a  total  of  13  out  of  39  cases,  or  exactly  1  in  3, 
rheumatism  was  certainly  known,  or  alleged  on  good  grounds,  to 
have  been  the  starting-point  of  the  mischief."'^  "  Of  pericarditis 
not  in  alliance  with  rheumatism,  Corvisart  gives  five  cases,  and  it 
was  complicated  with  inflammation  of  other  parts  in  all  of  them 
except  one,  and  in  this  it  was  caused  by  a  severe  blow  upon  the 
region  of  the  heart. "f  It  may  arise  from  the  extension  of  pleurisy 
or  pneumonia,  or  be  associated  with  renal  disease,  chorea,  measles, 
or  scarlatina.:};     Andral  has  met  with  it  as  a  complication  of  small- 

*  West,  On  the  Diseases  of  Infancy  and  Childhood,  1859,  p.  481. 

"  In  2  cases  of  pericarditis,  in  3  of  acute,  and  1  of  chronic  endocarditis,  or  fi  out  of 
39  instances,  tlie  disease  of  tiie  heart  was  traced  to  an  attack  of  scai-let  fever.  The 
cardiac  symptoms  did  not  manifest  themselves  in  tho  acute  stage  of  the  afl'ection,  but 
during  the  process  of  desquamation.  They  were  accompanied  by  fever  and  anasarca, 
which,  however,  did  not  exceed  mere  puffiness  of  the  face  and  extremities,  until,  in  the 
two  instances  of  pericarditis,  both  of  which  ran  a  chronic  course,  dropsy  came  on  as 
the  consequence  of  the  heart  disease." — Ibid. 

t  Dr.  P.  M.  Latham,  On  Diseases  of  the  Heart,  New  Syd.  Soc,  1876,  vol.  i,  p.  219. 

X  "  Pericarditis  is  not  frequent  in  cases  of  acute  Bright's  disease  from  scarlet  fever 
in  the  young,  since  it  only  occurred  in  1  in  14,  or  7  per  cent,  of  the  patients  under 
16  years  of  age." — Sibson,  On  Pericarditis,  Eeynolds's  System  of  Medicine,  vol.  iv, 
p.  408.    • 


DISEASES    OF    THE    HEART.  537 

pox,  and  in  the  last  stages  of  tubercular  disease  of  the  lungs  with 
vomicae,  and  with  chronic  asthma  and  bronchial  congestion.  A 
case  in  which  the  pericardium  was  greatly  inflamed,  and  contained 
an  abundance  of  turbid  yellow  serum  and  lymph,  is  recorded  by 
Dr.  Dyce  Duckworth.  The  child  was  only  eight  months  old,  and 
the  disease  appeared  to  follow  on  enlargement  of  the  bronchial 
and  mesenteric  glands.  After  death  no  tubercle  was  found  in  the 
pericardium  or  brain,  but  it  Avas  general  in  the  pleurfe,  lungs, 
liver,  and  spleen.* 

Treatment. — The  objects  to  be  aimed  at  are  to  reduce  the  inflam- 
mation and  to  favor  the  absorption  of  the  eflused  fluid.  Leeches 
may  be  applied  to  the  cardiac  region  in  strong  subjects,  and  there 
can  be  no  question  of  their  service  where  the  pain  is  very  acute 
and  the  pulse  is  frequent  and  hard,  but  venesection  is  never  neces- 
sary in  children,  however  robust  they  may  be,  because  reduction 
of  the  strength  has  to  be  feared,  especially  as  the  complaint  fre- 
quently follows  rheumatism,  when  the  constitution,  already  low, 
will  not  bear  further  depression,  and  the  blood  in  many  instances 
is  poor  and  aqueous.  A  strong  mustard  poultice  is  about  the  best 
application  ;  its  action  is  quick,  it  can  be  obtained  at  a  moment's 
notice,  and  when  the  child  complains  of  the  smarting  it  may  occa- 
sion, it  can  be  removed  at  once  In  cases  of  acute  pericarditis 
accompanying  rheumatic  fever  in  children,  I  have  found  these 
poultices  act  most  beneficially,  quickly  relieving  the  prtecordial 
distress  and  uneasiness,  and  I  believe  controlling  the  efi"usion. 
The  chest  should  be  covered  with  cotton-w^ool  immediately  the 
poultice  is  removed. 

The  next  remedy  of  service  is  counter-irritation.  I  should  not 
hesitate  to  employ  a  blister  whilst  the  skin  is  reddened  from  the 
rubefacient  effects  of  the  mustard.  The  surface  should  be  painted 
over  with  strong  blistering  fluid,  and  the  chest  protected  after- 
wards with  cotton-wool.  I  have  never  known  it  do  any  harm, 
but  the  late  Dr.  Sibson  was  opposed  to  blistering,  on  the  ground 
that  it  inflicted  local  injury,  tainted  the  blood  by  increasing  its 
fibrin,  and  prolonged  the  inflammation.  He  strongly  advocated 
"  the  application  of  chloroform  over  the  seat  of  suftering,  com- 
bined with  belladonna  liniment,  sprinkled  on  cotton-wool,  and 
covered  with  oiled  silk."t  After  the  action  of  the  blister,  an 
ointment  composed  of  equal  parts  of  savin  and  mercurial  oint- 

*  Path.  Transactions,  1875,  vol.  xxvi,  p.  246.  f  Op.  cit.,  p*.  433. 


538  DISEASES    OF    CHILDREN. 

ment  should  be  spread  on  lint  and  applied  to  the  prsecordial 
region.  Another  excellent  application,  after  the  blister  has  risen, 
is  a  combination  of  mercurial  ointment  and  powdered  opium  (oj 
ad  oj)  recommended  many  years  ago  by  Dr.  Beale. 

Hot  fomentations  are  unsatisfactory,  because  they  necessitate 
exposure  of  the  patient's  chest  during  their  employment,  and  it  is 
doubtful  whether  they  can  be  borne  hot  enough  to  be  of  any 
benefit.  Then  there  is  the  danger  of  getting  a  cold  or  chill, 
which  ought  to  be  guarded  against,  and  so  likely  is  this  to  hap- 
pen that,  if  the  case  goes  on  satisfactorily,  it  is  a  great  mistake 
to  institute  frequent  stethoseopic  examinations  of  the  chest. 

Mercury  may  be  given  as  an  aperient,  but  not  with  the  view  of 
fulfilling  any  special  indications,  and  in  rheumatic  cases  it  re- 
quires great  caution.  If  inflammatory  fever  runs  high,  and  there 
is  thirst,  elevation  of  temperature,  and  scanty,  turbid  urine,  then 
a  general  antiphlogistic  treatment  may  be  carried  out,  and  aperi- 
ents, diuretics,  nitrate  and  bicarbonate  of  potash  will  be  required. 
Even  aconite  is  sometimes  useful  if  the  skin  lacks  moisture,  and 
quinine  may  be  given  advantageouslj^  in  small  doses  if  the  tem- 
perature is  disposed  to  run  high  and  there  are  indications  of 
exhaustion. 

Opium  should  be  emploj-ed  if  there  is  much  pain,  as  the  con- 
tinuance of  it  further  reduces  the  strength  of  the  patient,  it 
diminishes  the  cardiac  contractions,  and  controls  the  hurried 
circulation ;  but  if  the  heart  gets  feeble,  the  respiration  hurried, 
and  the  countenance  at  all  livid,  then  stimulants,  in  the  form  of 
wine  or  brandy,  ammonia,  and  ether  will  be  required. 

Chronic  pericarditis  is  usually  a  sequel  of  an  acute  attack  of 
rheumatic  fever,  and  is  not  frequent  in  children.  The  chief  symp- 
toms are  pain  in  the  region  of  the  heart,  and  inability  to  lie  on 
the  left  side,  or  with  the  shoulders  low.  The  changes  produced 
in  the  pericardium  where  the  acute  attack  has  not  ended  in  reso- 
lution, are  thickening  or  adhesion  of  the  pericardial  surfaces,  and 
efl:usion  of  lymph  or  pus.  In  consequence  of  this  change  the  ac- 
tion of  the  heart  is  embarrassed,  and  the  muscular  structure  of  its 
walls  becomes  hypertrophied.  When  adhesion  takes  place  the 
action  of  the  heart  is  rolling  or  tumbling,  and  it  can  be  observed 
over  a  large  space  ;  the  apex  is  seen  beating  in  the  epigastrium, 
which  is  retracted.  With  these  changes  the  face  is  often  dusky 
and  anxious,  and  if  with  the  acute  pericardial  attacks  the  endo- 


DISEASES    OF   THE    HEART.  539 

cardium  has  been  also  involved,  we  may  have  evidences  of  valvular 
disease. 

The  treatment  consists  in  meeting  the  symptoms  that  arise,  by 
blisters  to  the  chest,  active  saline  aperients  to  relieve  the  oppressed 
circulation,  and  antirheumatic  remedies,  as  iron,  quinine,  and 
iodide  of  potassium. 

JHi/dropericardium. — Pericardial  effusion  may  be  the  result  of 
acute  or  chronic  pericarditis.  The  physical  signs  are  a  gradual 
increase  in  the  transverse  dulness  just  below  the  base  of  the  heart, 
and  displacement  of  the  lungs.  The  dulness  may  extend  across 
the  thorax  from  the  right  nipple  to  the  line  of  the  left  axilla,  and 
as  high  up  as  the  top  of  the  sternum.  In  all  eft'usions  into  the 
pericardium,  however  small  or  large,  dulness  extending  upwards 
is  the  surest  diagnostic  sign  from  cardiac  hypertrophy. 

The  amount  of  effusion  by  separating  the  heart  from  the  chest- 
wall  causes  its  impulse  to  be  w^eak,  and  bulging  of  the  prascordia 
may   ensue.      The   liver,  spleen,    and   diaphragm  are  depressed. 
Adherent  pericardium  leads  to  dilatation  and  hypertrophy  of  the ' 
heart. 

The  symptoms  in  the  case  of  a  lad  aged  13,  who  came  under  my 
notice  in  1864,  were  as  follows:  The  patient  was  suffering  from 
rheumatic  fever.  On  the  fifth  day  of  the  attack,  acute  pericarditis 
came  on,  and  four  days  later  there  were  all  the  symptoms  of  ex- 
tensive pericardial  effusion.  The  patient  had  to  be  propp:d  up  in 
bed  from  the  severity  of  the  dyspnoea,  and  he  could  not  lie  down 
for  a  moment  without  threatening  suffocation.  The  pulse,  through- 
out small,  became  fluttering,  and  for  some*  hours  imperceptible  at 
the  wrist ;  the  skin  was  bathed  in  sweat,  low  muttering  delirium 
was  fre(iuent,  and  the  patient's  life  was  despaired  of.  The  dulness 
extended  nearly  across  the  sternum  from  one  nipple  to  the  other, 
and  as  high  as  the  second  rib.  The  heart's  action  could  not  be 
detected,  but  there  was  no  palpable  prominence  of  the  prtecordial 
region.  The  patient  recovered  without  any  after  bad  effects,  either 
local  or  constitutional. 

The  treatment  consists  iu  giving  aperients  and  diuretics.  Blisters 
and  counter-irritants  should  be  applied  to  the  chest.  When  there 
is  no  chance  of  the  effusion  becoming  absorbed,  an  aspirator  should 
be  passed  through  the  fifth  intercostal  space,  and  some  of  the  fluid 
drawn  off'. 

An  interesting  case  of  pericardial  effusion  is  recorded  by  Dr. 


540  DISEASES    OF    CHILDREN. 

Barlow,  in  a  boy  six  years  of  age.  "  Twice  the  pericardium  was 
tapped  by  the  aspirator,  and  twice  the  abdomen,  with  marked  re- 
lief, and  without  any  bad  effects  from  the  operation.  The  child 
was  feverish  throughout,  and  neither  the  fever  nor  the  considera- 
ble ascites  could  be  satisfactorily  explained  during  life,  but  after 
death  these  were  found  to  be  due  to  tubercular  peritonitis.''* 

The  purely  passive  form  of  effusion  from  obstruction  to  the 
circulation  presents  the  same  symptoms,  and  the  treatment  is  also 
similar. 

Endocarditis. — This  disease  consists  in  inflammation  of  the  endo- 
cardium or  lining  membrane  of  the  heart,  and  is  frequently  asso- 
ciated with  pericarditis  as  a  consequence  of  acute  rheumatism.  It 
is  most  common  in  the  latter  affection,  but  it  maj^  arise  from  ex- 
posure to  cold,  be  developed  in  the  course  of  severe  chorea,  or 
scarlet  fever,  or  measles,  or  small-pox.  Bright's  disease  may  induce 
a  chronic  form. 

The  general  symptoms  are  a  sense  of  discomfort  and  uneasiness 
over  the  cardiac  region,  anxiety  of  expression;  flushed  countenance, 
and  a  tendency  to  sj-ncope.  Pain  is  not  always  present  unless  there 
is  pericarditis  or  pleurisy,  and  if  auscultation  were  not  practiced 
carefully  the  disease  might  be  overlooked.  Still,  in  a  few  instances 
pain  is  severe,  and  increased  on  the  slightest  pressure  or  movement, 
so  that  the  weight  of  the  bedclothes  is  intolerable.  There  is  rest- 
lessness, hot  skin,  thirst,  and  fever,  followed  by  perspiration,  which 
is  often  profuse  as  the  disease  advances ;  the  pulse  soon  becomes 
quick,  feeble,  or  intermittent,  and  the  breathing  is  hurried  and 
abdominal.  As  the  disease  progresses  the  lips  become  livid,  the 
eye  is  dim,  and  the  face  is  dull  and  heav}-,  or  pale  and  shrunken. 
^Vandering  at  night,  and  even  delirium  and  convulsions  are  among 
the  sj-mptoms.  Bronchial  congestion,  or  pulmonary  engorgement 
is  apt  to  ensue  from  increasing  debilitj',  and  to  failure  of  the  cir- 
culation throuo;h  the  luna;s. 

The  j^^'y^ical  signs  are  those  indicating  mischief  at  the  aortic 
and  mitral  orifices,  as  mentioned  under  valvular  affections;  there 
is  usually  a  soft  bruit  at  the  apex  with  the  systole,  but  the  symp- 
toms depend  on  the  valves  which  are  affected,  and  these  are 
generally  on  the  left  side  of  the  heart.  The  disease  may  termi- 
nate fatally  from  exhaustion  and  cerebral  symptoms,  or,  if  the 

*  On  a  ca.se  of  Pericardial  Effusion,  in  which  Paracentesb  was  performed,  Prac- 
titioner, 1873,  vol.  xi,  p.  265. 


DISEASES   OF   TPIE    HEART.  541 

acute  stage  be  passed  over,  no  traces  of  tlie  disease  may  remain. 
In  most  severe  cases  valvular  changes  ensue,  leading  to  puckering 
of  the  valves  and  impairment  of  their  functions,  with  ultimate 
obstruction  of  the  circulation  and  general  dropsy.  A  portion  of 
coagula  may  be  detached  from  the  curtain  of  the  inflamed  valve 
and  carried  into  the  2;eneral  circulation,  causinof  embolism. 

In  endocarditis  as  the  accompaniment  of  rheumatic  fever  there 
is  an  inflammation  of  the  lining  membrane  of  the  heart.  Efi:usion 
of  Ij'mph  into  the  structure  of  the  valves  [mitral  valvulitis)  ensues, 
which  finally  becomes  converted  into  a  fibrous  structure,  the 
chordae  tendine?e  are  involved,  so  that  they  undergo  contraction, 
and  the  valves  become  tied  down  or  puckered  up  together,  which 
either  narrows  the  mitral  orifice  [mitral  stenosis)  or  the  opening  is 
so  wide  that  when  the  ventricle  contracts  regurgitation  is  produced 
[mitral  regurgitation).  The  mitral  valve  at  each  ventricular  con- 
traction has  to  sustain  much  greater  pressure  than  the  aortic  valve, 
which  has  only  to  bear  the  force  of  the  returning  blood  against  it. 

Treatment. — This  should  in  some  measure  depend  upon  the  dis- 
ease with  which  the  cardiac  afiection  is  complicated,  and  seeing 
that  it  may  arise  in  the  course  of  acute  rheumatism  or  scarlet 
fever,  it  will  be  important  to  modify  the  treatment  accordingly.  The 
treatment  is  really  that  of  pericarditis,  with  which  it  is  often  as- 
sociated, but  there  is  this  diiierence,  endocarditis  speedily  tends  to 
exhaustion,  and  is  not  so  amenable  to  active  agents  as  venesection 
and  counter-irritation.  The  patient  should  remain  in  bed  for  a 
length  of  time  after  the  acute  stage  has  passed  over,  so  that  ex- 
citement may  be  diminished,  and  the  efi:ect8  of  strain  should  be 
kept  ofi'  the  injured  valves  by  lowering  the  blood  pressure  as  far 
as  possible.  For  such  purpose  chloral  hydrate  is  indicated.  This 
is  dwelt  upon  by  Dr.  Milner  Fothergill,  in  a  lecture,  in  the  ^leiV- 
cal  Times  and  Gazette,  Sept.,  1878.  "This  fact,  then,  is  ascer- 
tained and  confirmed  by  experience,  viz.,  that  the  damage  done  to 
the  endocardium  by  rheumatic  inflammation  may  abide  for  four 
or  five  years  without  producing  any  conscious  detriment  to  the 
health  or  well-being  of  the  patient,  or  (as  far  as  we  have  the  means 
of  judging)  any  farther  injury  to  the  structure  of  the  heart.  And 
it  is  a  most  important  and  consolatory  fact.  But  in  other  instances 
other  results  immediately  follow.  When  after  its  departure  acute 
rheumatism  leaves  the  endocardial  murmur  behind  it,  which, 
though  known  only  to  the  physician,  is   the  sure  sign  of  injury 


542  DISEASES   OF   CHILDREN. 

done  to  the  endocardium,  it  leaves  it  attended  from  the  beginning 
by  other  symptoms,  which  the  patient  is  sufficiently  conscious  of, 
and  these  are  directly  referable  to  the  heart.  They  consist  of  pal- 
pitation, and  some  pains,  and  some  dyspnoea,  which  are  not  con- 
stantly present,  but  only  under  bodily  exertion  and  mental  excite- 
ment. The  child  who  has  had  the  prsecordial  murmur  ever  since 
it  suffered  a  certain  rheumatic  attack,  is  just  the  same  child  as  it 
was  before,  except  that  it  cannot  join  in  any  pastime  requiring 
rapid  movement;  fur  then  its  heart  palpitates,  it  loses  its  breath, 
and  is  obliged  to  sit  down.  Men  too  are  just  the  same  men  as 
they  were  before,  only  perhaps  they  cannot  run  upstairs  without 
panting  and  hurr3^,and  they  constantly  find  themselves  obliged  to 
restrain  their  bodily  efforts  within  certain  limits,  and  to  beware 
of  mental  excitement,  for  fear  of  palpitation  and  dyspnoea.  These 
conditions  too  may  remain  for  years  without  either  augmentation 
or  abatement.  The  murmur  is  never  absent,  but  the  palpitation 
and  dyspnoea  are  never  present  except  as  the  immediate  effect  of 
a  certain  amount  of  bodily  exertion  or  mental  excitement."* 

Myocarditis  or  inflammation  of  the  heart's  substance  is  generally 
found  in  connection  with  endocarditis  or  pericarditis,  but  the 
muscular  structure  of  the  heart  may  be  affected  just  as  the  muscles 
are  in  subacute  or  chronic  rheumatism,  without  any  inflammation 
whatever.  Myocarditis  occurs  also  in  scarlet  fever  and  in  typhoid 
fever.  After  some  fatal  cases  of  endocarditis,  the  walls  of  the 
heart  have  been  found  to  be  thickened,  and  abscesses  of  variable 
size  have  been  discovered  in  the  muscular  structure  of  the  organ. 
Such  changes  sometimes  occur  in  death  from  pyaemia,  scarlet  fever, 
and  some  other  forms  of  blood-poisoning.  If  palpitation  and  vio- 
lent pains  in  the  cardiac  region  come  on  during  rheumatism,  and 
the  pain  extends  through  the  shoulder,  or  passes  down  the  arm, 
the  disease  may  be  suspected.  The  complaint  being  obscure  in  its 
manifestations,  the  treatment  must  be  regulated  in  accordance 
with  the  most  urgent  symptoms  and  the  cause  in  operation,  if  it 
can  be  discovered. 

Ulcerative  Endocarditis. — This  disorder  superficially  resembles 
the  form  of  endocarditis,  frequent  in  rheumatic  subjects,  where 
minute  coagula  form  around  endocardial  vegetations,  and  becom- 
ing detached,  produce  embolism  in  the  cerebral  and  other  arteries. 
But  in  ulcerative  endocarditis  the  blood  is  previously  poisoned  by 


*  Dr.  P.  M.  Latham,  On  Diseases  of  the  Heart,  New  Syd.  Soc,  1876,  vol.  i,  p.  279. 


DISEASES    OF    THE    HEART.  513 

some  specific  affection,  as  small-pox,  pyemia,  diphtheria,  etc.,  and 
coagula  of  infected  blood  form  around  the  cardiac  valves.  Por- 
tions of  these  clots  becoming  detached,  produce  embolism  of  an 
infective  character  over  and  above  their  purely  mechanical  effects. 
The  disease  attacks  only  persons  of  bad  constitution. 

For  much  of  the  description  now  about  to  be  given,  I  am  in- 
debted to  an  interesting  lecture  by  Dr.  Cayley,  on  a  case  of 
"  Ulcerative  or  infecling  endocarditis  simulating  typhoid  fever  in  a  hoy 
aged  nine  years."* 

The  disease  is  to  be  distinguished  anatomically  by  a  large 
number  of  embolisms  in  the  miliary  form.  The  emboli  in  ordi- 
nary endocarditis  are  lodged  in  the  middle  cerebral  artery,  pro- 
ducing hgemorrhage  and  softening  of  the  corpus  striatum  and  optic 
thalami,  followed  by  hemiplegia.  In  ulcerative  endocarditis  they 
are  deposited  in  the  pia  mater  of  the  hemispheres,  and  do  not  ^ 
necessarily  produce  any  cerebral  lesion.  The  intestine  is  frequently 
the  seat  of  emboli  in  this  form  of  endocarditis,  and  in  both  varie- 
ties the  kidneys  and  spleen  are  the  most  common  seats  of  em- 
bolism. ,  The  endocarditis  of  acute  rheumatism  may  occasionally 
assume  this  variety,  and  it  may  even  supervene  on  chronic  valvular 

disease. t 

The  general  symptoms  sometimes  resemble  ordinary  pyaemia  ; 
there  are  rigors,  high  fever  of  a  remittent  or  intermittent  type, 
and  local  suppurations.  In  other  cases  they  resemble  typhoid 
fever,  as  in  the  case  recorded  by  Dr.  Cayley. 

In  the  typhoid  form  there  are  rigors  and  vomiting,  often  sweat- 

*  Medical  Times  and  Gazette,  November  10th,  1877,  p.  509. 

A  case  of  a  boy,  pet.  14,  terminated  fatally,  through  rupture  of  the  heart,  almost  im- 
mediately after  admission  into  hospital.  A  year  previously  he  had  an  attack  of  rheu- 
matic fever,  and  since  then  had  been  losing  flesh,  and  suffered  from  dyspnoea  on  exer- 
tion. A  fortnight.before  admission  he  had  severe  pain  in  the  chest,  constant  dyspnoea, 
and  general  malaise.  When  admitted  there  was  a  thrill,  a  double  murmur  over  the 
aortic  valves,  and  a  systolic  murmur  at  the  apex.  "  He  suddenly  became  insensible, 
flushed  in  the  face,  and  began  to  struggle,  and  then  turned  deadly  pale  and  died."  A 
post-mortera  examination  showed  that  "the  pericardium  was  full  of  coagulated  blood, 
which  had  flowed  from  a  very  small  orifice  in  a  sac  lying  between  the  aorta  and  pul- 
monary vein,  and  which  was  formed  by  the  protrusion  of  tlie  i^art  lying  at  the  base  of 
the  mitral  valve,  in  which  destructive  inflammatory  ulceration  had  produced  the 
lesion."— ^<.  George's  Hosp.  Rep.,  1874-76,  p.  367. 

f  "The  average  weight  of  the  spleen  in  ten  cases  of  ulcerative  endocarditis  occurring 
in  1867-70  was  25  oz. ;  they  were  always  more  or  less  soft  and  pulpy.  Very  rarely 
the  spleen  readies  even  to  double  the  latter  weight  in  endocarditis." — Path.  Anatomy, 
by  Wilks  and  Moxon,  1875,  p.  475. 


544  DISEASES    OF    CHILDEEX. 

ino",  and  irres-ular  febrile  exacerbations.  There  are  also  brown 
tongue,  sordes  on  the  teetli,  and  delirium  passing  into  coma.  The 
urine  is  often  bloody  and  albuminous. 

Auscultation  discovers  the  signs  of  valvular  obstruction,  tbe 
murmurs  varying  according  to  the  oriiices  afl'ected  and  the  prog- 
ress of  tbe  ulceration. 

The  disease  tends  to  a  fatal  termination,  and  is  not  controlled 
by  treatment. 

Valvular  Diseases  of  the  Heart. 

The  general  symptoms  of  valvular  disease  of  the  beart  may  be 
thus  briefly  stated.  The  blood  is  either  impeded  in  its  passage 
throucrb  the  oro;an,  or  it  reo;ur";itates  from  defect  in  the  closure  of 
the  valves,  and  this  leads  to  hypertroph}-  with  congestion  of  the 
lungs  and  other  organs,  followed  by  dropsj^  The  symptoms  vary 
a  good  deal,  and  in  children,  even  when  tbe  valvular  condition 
and  hypertrophy  appear  to  be  about  equal,  tbe  constitution  suffers 
differently.  This  arises  from  the  conservative  process  of  hyper- 
trophy, which,  for  a  long  time,  keeps  in  cheek  the  symptoms ; 
but,  by-and-by,  the  heart  laboring  to  empty  its  overplus,  fails,  and 
congestion  of  the  venous  system  follows.  Then  ensue  hurried 
respiration,  dj'spnoea,  pain  in  the  region  of  the  heart  or  palpita- 
tion, anxiety  of  expression,  pallor  or  suffusion  of  the  face,  inability 
to  walk  upstairs,  and  the  impossibility  of  resting  in  the  recum- 
bent position.  The  symptoms  are  increased  by  indigestion  or 
mental  emotion.  The  valves  on  the  left  side  of  the  heart  are  far 
more  prone  to  disease  than  those  on  the  right.  When  the  latter 
are  affected  it  has  been  attributed  to  fetal  endocarditis. 

The  constitutional  symptoms  in  these  cases  are  liable  to  con- 
siderable variation.  Some  children  who  have  all  the  i^hysical 
signs  of  a  severely  damaged  valve,  as  the  consequence  of  rheu- 
matic endocarditis,  experience  no  breathlessness  and  scarcely  any 
other  discomfort.  They  may  go  on  for  months  or  years  with 
very  little  complaint.  I  have  more  than  once  known  the  heart 
entirely  overlooked  in  these  cases,  and  the  symptoms  of  impaired 
health  ascribed  to  weakness  and  general  debility.  But  later  on 
the  sjTnptoms  of  obstruction  to  the  circulation  begin  to  be  mani- 
fest, and  there  are  cough,  congestion  of  the  lungs,  and  hurried 
breathing.      In   prolonged    casts   the  liver   and  digestive  organs 


DISEASES   OF   THE   HEART.  545 

become  deranged,  the  features  are  swelled,  and  oedema  of  the 
extremities  supervene. 

Disease  of  the  aortic  valves  is  so  rare  in  childhood  that  it  might 
be  passed  over  unnoticed.  But,  since  it  does  now  and  then  occur 
in  children,  it  is  well  to  call  attention  to  this  lesion.  When  the 
aortic  orifice  is  narrowed  or  constricted  [aortic  obstruction — aortic 
stenosis),  the  blood  is  impeded  in  its  passage  from  the  left  ven- 
tricle. Over  the  midsternum,  but  more  especially  over  the  second 
right  costal  cartilage,  and  in  the  course  of  the  aorta  and  carotids, 
a  soft  systolic  murmur,  corresponding  in  time  with  the  j^nlse,  is 
heard,  diminishing  in  intensity  towards  the  apex.  A  systolic 
thrill  is  often  felt  over  the  cardiac  region,  at  the  right  base,  with 
heaving  impulse.  There  is  usually  great  hypertrophy^  of  tlie  left 
ventricle.  If  the  heart's  action  is  weak,  and  the  narrowing  of 
the  orifice  smooth,  the  murmur  may  not  be  easily  detected. 
When  the  narrowing  is  great  the  pulse  is  small  and  feeble,  but 
this  will  in  some  degree  depend  upon  the  amount  of  hypertrophy 
present,  which  modifies  its  character.  The  constitutional  symp- 
toms are  pallor  of  the  countenance,  and  often  headache  from 
cerebral  anaemia,  owing  to  the  unfilled  state  of  the  arteries.  Un- 
less the  mitral  valve  becomes  involved,  so  as  to  allow  of  regurgi- 
tation taking  place,  the  pulmonary  circulation  is  not  interfered 
with. 

Causes. — These  are  most  probably  due  to  chronic  valvulitis  and 
to  endocarditis  after  rheumatic  fever.  When  rheumatic  endo- 
carditis happens,  the  inflammation  begins  in  the  mitral  valve,  and 
then,  after  involving  the  ventricular  endocardium,  seizes  upon  the 
aortic  valves.  The  form  assumed  by  aortic  valvulitis  in  child- 
hood is  certainly  that  of  regurgitation  ;  the  distortion  and  muti- 
lation of  the  valves  commences  in  the  free  edges,  and  is  usually 
accompanied  by  dilatation  of  the  aortic  conus  and  the  actual 
enlargement  of  the  aortic  ostium. 

When  the  aortic  valves  cannot  effectually  close  the  orifice  on  the 
aortic  recoil,  the  blood-stream  returns  into  the  ventricle,  and  ao?Mc 
regurgitation  is  produced.  The  physical  signs  are  a  diastolic  mur- 
mur, heard  at  the  midsternum,  obliterating  the  second  sound, 
and  frequently  distinctly  audible  at  the  apex.  It  may  be  soft  or 
rough,  weak  or  loud,  musical  or  prolonged.  The  pulse  is  sudden 
and  jerky;  it  is  known  as  "  Corrigan's  pulse,"  collapsing,  "like 

35 


546  DISEASES   OF   CHILDEEN. 

balls  of  blood  shot  under  the  fingers,"  but  there  may  be  consider- 
able regurgitation  without  this  being  marked,  or  any  visible  pul- 
sation in  the  superficial  vessels. 

The  tendency  of  the  disease  is  to  produce  extreme  hypertrophy 
of  the  left  ventricle,  but  very  rarely  any  dropsy.  The  ventricle 
being  always  too  full  of  blood,  undergoes  comparative  hypertrophy, 
and  containing  blood  in  diastole,  dilatation  is  added  to  hyper- 
trophy. 

Dr.  De  Havilland  Hall  afforded  me  an  opportunity  of  seeing  a 
patient  of  his,  a  boy  ten  years  of  age,  who  was  the  subject  of 
aortic  reo-ursitation.  Six  weeks  before  he  came  under  observa- 
tion  he  had  complained  of  paina  in  his  knees  and  feet,  and  had 
been  confined  to  bed  one  week.  When  seen  he  was  sufiering  from 
weakness  and  giddiness,  and  some  shortness  of  breath  on  exer- 
tion. On  examination,  he  was  found  to  have  a  soft  aortic  dias- 
tolic murmur,  heard  loudest  over  the  third  right  interspace  close  to 
the  sternum,  and  conducted  along  the  sternum  to  the  apex.  The 
impulse  was  greatly  diftused,  but  most  marked  in  the  fifth  inter- 
space in  the  nipple-line.  There  was  visible  pulsation  in  the  bra- 
chial arteries. 

Causes. — This  affection  msiy  possibly  be  congenital.  It  may 
also  follow  chronic  changes,  violent  strains,  and  endocarditis  after 
rheumatism  in  obstructive  disease. 

Disease  of  the  right  auriculo-ventricular  orifice  {tricuspid  regurgita- 
tion) is  rare,  and  murmurs  are  uncommon  in  this  situation,  except 
in  long-standing  cases  of  mitral  disease,  in  which  the  right  side  of 
the  heart  has  become  weakened,  and  there  is  obstruction  to  the 
pulmonary  circulation.  "  Mitral  stenosis  is  the  most  frequent 
cause  of  serious  tricuspid  regurgitation,  and  the  earlier  in  life  the 
stenosis  occurs,  the  more  rapidly,  as  a  rule,  the  tricuspid  regurgi- 
tation follows,  and  the  more  serious  the  prognosis."*  The  physi- 
cal signs  are  increased  praecordial  dulness  to  the  right  of  the 
sternum,  at  the  level  of  the  fourth  rib,  and  epigastric  pulsation, 
the  ventricle,  being  seen  and  felt  between  the  ensiform  cartilage 
and  receding  ribs  in  the  left  hypochondrium.  Owing  to  the  accu- 
nmlation  of  blood  in  the  right  ventricle  from  congestion  of  the 
lungs,  it  becomes  enlarged  and  dilated.  As  it  encroaches  on  the 
position  of  the  left  ventricle,  and  lies  in  front  of  it,  the  apex  is 
pushed  away  from  the  chest-wall,  and  the  impulse  is  extremely 

*  Balfour,  op.  cit.,  p.  181. 


DISEASES   OF  THE   HEART.  547 

weak  or  cannot  be  felt  at  all.  .  A  murmur  usually  accompanies 
the  systole,  and  is  most  audible  over  the  lower  part  of  the  ster- 
num, or  ensiform  cartilage.  I  say  usually,  because  the  murmur 
is  altogether  absent  in  some  cases,  and  in  others  it  cannot  be 
detected,  though  the  other  signs  of  tricuspid  incompetency  are 
all  present.  Accentuations  of  the  pulmonary  second  sound  should 
be  looked  for,  and  weakness  of  the  aortic  second.  The  increased 
outline  can  often  be  distinguished  readily  enough  in  children 
whose  chest-walls  are  thin,  and  the  left  lobe  of  the  liver  may 
receive  an  impulse,  while  at  the  same  time  the  liVer  is  not  unfre- 
quently  enlarged.  This  condition  is  often  attended  with  overfulness 
of  the  cervical  veins,  because  the  right  auricle  is  overdistended,  and 
in  fact  the  right  side  of  the  heart  altogether  undergoes  passive 
dilatation.  The  tricuspid  being  insufficient,  each  contraction  of 
the  right  ventricle  drives  backwards  the  blood  into  the  right 
auricle  and  the  veins  in  communication  with  it.  The  wavy  pul- 
sation in  the  external  jugular  veins  is  an  indication  of  considerable 
tricuspid  regurgitation,  but  if  the  orifice  is  only  slightly  contracted, 
then  the  valve  may  act  efficiently,  and  the  pulsation  in  the  vein 
be  absent.  Congestion  of  the  intestinal  veins,  scanty  urine,  and 
even  haemorrhoids,  are  sometimes  present.  In  a  boy,  aged  eleven 
years,  under  my  care  in  1877  for  mitral  and  tricuspid  disease, 
oedema  and  anasarca  of  the  lower  extremities  came  on  a  month 
before  death. 

"When  the  cardiac  enlargement  exists  to  the  same  extent  in  two 
separate  cases,  we  may  have  in  one  case  regular  bowels  and  normal 
extremities  with  the  power  to  lie  down  and  assume  any  position  ; 
whilst  in  another  case  there  are  severe  and  continuous  congestive 
headache,  enlarged  veins  in  the  neck,  and  pulmonary  engorge- 
ment. This  depends  upon  the  amount  of  injury  the  valve  has 
sustained.  If  the  tricuspid  orifice  is  only  partially  constricted, 
and  there  is  no  defect  in  the  valves,  the  venous  circulation  is 
partially  congested ;  for  it  should  be  held  in  mind  that  a  murmur 
in  this  situation,  like  a  mitral  regurgitant  murmur,  may  be  simply 
the  expression  of  great  debility. 

A  systolic  murmur  heard  most  distinctly  over  the  pulmonary 
orifice  is  generally  due  to  anaemia,  or  to  pressure  by  consolidated 
lung.     When  organic  it  is  almost  always  congenital. 

Disease  of  the  left  auriculo-ventriculcu^  [mitral)  valve,  causing 
reo;uro;itation  from  the  ventricle  into  the  auricle,  is  the  most  com- 


548  DISEASES   OF   CHILDEElSr. 

mon  form  of  cardiac  disease  to  b.e  met  with.  It  is  evidenced  by 
a  murmur,  diastolic  in  time,  and  unlike  that  of  mitral  stenosis  is 
not  caused  by  the  contraction  of  the  auricle.  It  is  very  much 
more  frequent  in  girls  than  boys.  In  these  cases  there  is  enlarge- 
ment of  the  left  ventricle,  and  the  apex-beat  is  below  and  external 
to  the  nipple  ;  it  often  occupies  a  larger  space  than  in  health, 
except  when  it  strikes  directly  behind  a  rib,  and  then  it  is  not 
detected  so  readily.  The  impulse  is  considerable  and  heaving, 
and  if  the  hand  be  placed  over  the  pr?ecordial  region,  there  is  an 
appreciable  thrill.  Over  the  apex  is  a  bruit  accompanying  the 
systole,  partially  obscuring  the  first  sound,  and  diminishing,  or 
even  disappearing  at  the  base,  if  only  slight ;  but  if  loud  or 
intense,  it  may  almost  obliterate  the  second  sound  at  the  apex, 
and  be  detected  over  the  whole  prsecordial  region.  The  murmur 
is  synchronous  with  the  pulse,  and  owing  to  the  blood  being 
carried  back  into  the  left  auricle,  can  be  heard  in  the  left  axilla,  at 
the  angle  of  the  scapula  on  the  same  side,  and  at  the  spinal 
column.  The  pulmonary  second  sound  is  generally  intensified. 
This  murmur  {bruit  de  soufflet)  is  soft  and  bellows-like  in  recent 
cases,  where  possibly  the  deposit  on  the  valve  has  become  highly 
organized,  but  in  more  advanced  cases  it  is  rough  and  grating, 
and  resembles  the  sawing  of  wood.  The  peculiar  vibratory 
motion  (purring  tremor— fremissemeni  caiaire)  occasionally  found 
in  disease  of  the  mitral  orifice  is  essentially  connected  with 
obstructive,  and  rarely  if  ever  with  mitral  regurgitant  disease. 
Cough,  congestion  of  the  lungs,  quick  breathing,  and  a  small  con- 
tracted pulse,  are  common  in  these  cases. 

A  loud  apex  murmur  in  mitral  disease  is  compatible  with  fair 
strength  and  growth,  and  may  be  present  without  impairing  the 
functions  of  the  heart.  In  such  cases  there  is  probably  a  mere 
roughening  of  the  surface  of  the  valves,  or  even  a  vegetation, 
which  does  not  permit  any  of  the  blood  in  the  ventricle  to  flow 
back  through  the  mitral  orifice,  yet  a  systolic  apex-bruit  ma}'-  be 
present  and  regurgitation  take  place  with  a  competent  mitral 
valve.  "  In  fact,  the  mitral  valve  may  be  perfectly  free  from 
disease,  and  the  auriculo-ventricular  opening  perfectly  natural 
and  undilated,  and  yet  regurgitation  may  and  often  does  take 
place."*  In  anaemia  and  chlorosis,  a  venous  murmur  may  some- 
times be  heard  over  the  mitral  area,  accompanied  with  acceutua- 

*  Diseases  of  the  Heart,  Balfour,  1876,  p.  102. 


DISEASES    OF   THE    PIEART.  549 

tion  of  the  pulmonary  second  sound,  as  in  true  mitral  constriction 
and  regurgitation,  but  unassociated  with  any  valvular  lesion. 
There  are  other  cases  in  which  the  physical  signs  are  the  same, 
but  graver  mischief  has  been  done,  and  the  right  side  of  the  heart 
and  lungs  suffer  in  time.  Children  so  affected  are  small,  dwarfed, 
and  stunted,  and  liable  to  die  of  dropsy  at  puberty.  They  rarely 
get  over  the  pubertal  changes. 

Disease  of  ike  left  auriculo-ventricidar  orifice  {obstructive  disease), 
causing  contraction  of  the  orifice  [mitral  stenosis)  and  obstruction  to  the 
blood-flow  into  the  ventricle.  In  this  disease  congestion  of  the  lungs, 
hfemoptysis,  or  pulmonary  haemorrhage  may  ensue.  The  effects 
on  the  circulation  are  much  the  same  as  in  the  former  case.  Chronic 
bronchitis,  pneumonia,  and  urgent  dyspnoea,  general  venous  con- 
gestion, and  anasarca  must  be  looked  for.  After  a  time  the  em- 
barrassed pulmonary  circulation  affects  the  right  side  of  the  heart, 
and  its  cavities  become  enlarged  ;  there  is  increased  dulness  to  the 
right  side  of  the  sternum,  and  the  right  ventricle  may  be  seen  and 
felt  between  the  ensiform  cartilage  and  the  receding  ribs  to  the 
left  hypochondrium  in  long-standing  cases. 

Some  cases  of  mitral  constriction  are  supposed  to  be  of  congeni- 
tal origin,  and  they  continue  for  years  without  causing  any  sign 
of  heart  mischief. 

The  pathognomonic  phj^sical  sign  of  obstructive  disease  of  the 
mitral  valve  is  a  presystolic  murmur  [auricular  systolic),  and  when 
once  heard  there  can  exist  no  doubt  as  to  its  significance.  The 
murmur  is  produced  as  the  current  of  blood  in  its  natural  passage 
through  the  heart  encounters  resistance  at  the  contracted  valvular 
orifice ;  the  valves  being  converted  into  a  curtain  with  a  slit  in  it 
[the  button-hole  mitral),  or  into  a  fingerlike  cone  projecting  into  the 
ventricle.  The  bruit  immediately  precedes  the  first  sound  of  the 
heart  and  carotid  pulse ;  it  is  presystolic  in  character,  and  is  co- 
incident in  time  with  the  contraction  of  the  auricles,  and  not  that 
of  the  ventricles.  It  would  serve  no  practical  purpose  to  enter 
into  the  vexed  question  concerning  the  exact  time  during  the 
heart's  revolutions  at  which  this  murmur  is  produced,  but  I  would 
just  notice  a  remark  by  Dr.  Andrew  to  the  effect  that  it  occurs  at 
the  latter  part  of  the  diastole  and  seems  to  be  continuous  with  the 
first  sound,  from  which  it  is  difficult  to  distinguish  an  interval.* 
It  is  a  short  and  rough  murmur,  and  obliterates  the  second  sound 

*  On  Presystolic  Murmurs  at  the  Heart's  Apex,  St.  Barth.  Hosp.  Eep.,  vol.  xiii,  p.  1. 


550  DISEASES    OF    CHILDREN. 

at  the  apex,  but  intensifies  it  at  the  base.  Accentuation  of  the 
puhnonary  second  sound  is  one  of  the  most  constant  conditions  of 
mitral  stenosis.  Its  loudness,  lil?e  all  other  cardiac  murmurs,  de- 
pends upon  the  condition  of  the  blood  and  the  size  of  the  aperture, 
and  the  force  of  the  heart's  action ;  but  why  it  should  disappear 
from  time  to  time  whilst  the  constriction  remains  unaltered,  is  at 
present  unexplained.  A  cardiac  thrill  (diastolic)  is  usually  present, 
and  the  left  ventricle  is  contracted  and  its  walls  thin,  according  to 
Niemeyer,*  but  Dr.  Balfour  remarks :  "  as  we  never  have  mitral 
stenosis  without  regurgitation,  some  degree  of  hypertrophy  of  the 
left  ventricle  is  almost  always  present,  etc."t  The  left  auricle  is 
dilated  and  hypertrophied,  and  the  right  side  of  the  heart  also. 
The  pulse  is  occasionally  regular,  but  often  weak,  rapid,  and  irregu- 
lar. Mitral  obstruction  and  regurgitation  may  exist  together.:^ 
The  murmur  of  mitral  stenosis  is  heard  at  the  left  apex  and  in- 
clining towards  the  right  apex;  whilst  a  regurgitant  murmur  is 
carried  towards  the  axilla,  or  behind  from  the  left  nipple  to  the 
mesial  line  at  the  back.  It  is  heard  over  a  less  area  than  that  of 
regurgitation.  It  is  generally,  but  certainly  not  invariably,  limited 
to  the  mitral  area,  "  that  is,  within  a  circle  of  about  an  inch,  de- 
scribed round  the  point  where  the  apex  impinges  as  a  centre. "§ 
An  attack  of  pulmonary  catarrh,  with  elevation  of  temperature, 
will  often  render  the  murmur  softer  and  more  diffused. 

The  causes  which  induce  valvular  diseases  of  the  heart  in  chil- 
dren are  acute  rheumatism,  chronic  albuminuria,  chorea,  and  the 

*  Practical  Medicine,  1875,  vol.  i,  p.  353. 

f  Diseases  of  the  Heart,  1876,  p.  153. 

X  A  girl,  £et.  13,  of  rickety  constitution,  was  admitted  into  the  Samaritan  Hospital, 
under  my  care,  in  November,  1878,  with  symptoms  of  mitral  stenosis.  There  was  no 
history  of  rheumatism  or  chorea,  the  disease  being  probably  congenital.  Two  years 
previously  she  had  a  severe  cough,  and  threw  up  a  good  deal  of  blood.  The  lungs 
gave  some  proof  of  hypera^raia  and  congestion.  Tlie  lieart's  action  was  thumping  and 
sudden  ;  dulness  extended  to  the  sixth  interspace  below,  a  little  external  to  the  nipple 
line,  and  in  the  direction  of  the  epiga.strium.  There  was  some  hypertrophy  and  dila- 
tation on  the  left  side  of  the  heart.  There  was  no  thrill,  but  a  very  distinct  presystolic 
murmur,  limited  to  the  area  of  the  cardiac  apex,  of  a  cantering  sonorous  character, 
fading  in  force  towards  its  termination,  like  a  sound  dying  away  in  the  distance.  It 
was  well  vocalized  by  the  letters  Rrrh  or  Voot,  as  Dr.  Balfour  has  pointed  out  (op. 
cit.,  p.  110).  A  louder  and  different  murmur  was  heard  posteriorly,  and  in  the  axillary 
line,  also  in  diminished  force  over  the  right  chest  and  back ;  it  was  systolic  and  had 
all  the  characters  of  a  mitral  regurgitant  murmur.  Tlu;  pulse  averaged  90;  it  was 
jerking,  weak,  and  wavy,  but  regular. 

?i  Balfour,  op.  cit.,  p.  103. 


DISEASES    OF   THE   HEART.  551 

specific  fevers,  especially  scarlet  fever ;  indeed,  any  circumstance 
which  will  set  up  pericarditis  and  endocarditis  may  lead  to  dilata- 
tion or  contraction  of  the  cardiac  oritices,  and  to  adhesion  and 
rigidity  of  the  valves  which  guard  them.  Dr.  Hayden  considers 
the  poison  of  scarlet  fever  as  next  in  frequency  to  that  of  rheuma- 
tism in  producing  heart  disease.  "  Man}^  of  the  most  formidable 
examples  of  valvular  lesion  that  I  have  met  with  owed  their  origin 
to  scarlatina.  The  patients  are  generally  children,  and  rarely  sur- 
vive the  second  period  of  life.  The  complication  is  usually  de- 
clared in  the  second  week  of  the  fever,  but  occasionally  in  the  first 
week,  or  the  stage  of  desquamation."*  Endocarditis  is  set  up  as 
we  have  alread}^  seen  {vide  Endocarditis),  and  the  valves,  more 
especiall}"  the  mitral  valve,  become  involved  in  structural  change. 
Of  thirteen  cases  of  heart  disease  associated  with  sccwlaiina,  which 
came  under  Dr.  Sansom's  care,  there  were  three  cases  oi  pericarditis  ; 
one  case  was  uncomplicated,  and  two  cases  were  complicated  with 
endocarditis  (mitral  regurgitation).  There  were  ten  cases  of  endo- 
carditis, inducing  mitral  regurgitation  in  eight  cases,  one  case  of 
dilatation  of  left  and  right  cavities,  mitral  stenosis  in  one  case, 
mitral  stenosis  and  regurgitation  one  case.  In  six  cases  of  heart 
disease  associated  with  measles,  there  was  pericarditis  with  endo- 
carditis (mitral  regurgitation)  in  one  case ;  endocarditis  inducing 
mitral  regurgitation  in  three  cases.  In  one  case  hypertrophy  and 
dilatation ;  in  one  case  tricuspid  insufficiency  ;  in  one  case  mitral 
stenosis ;  in  one  case  mitral  stenosis  and  regurgitation. f 

Dr.  Dyce  Duckworth  has  collected  eighty  cases  of  mitral  ste- 
nosis, of  which  only  seventeen  were  males;  the  oldest  patient  was 
63,  the  youngest  (a  girl)  14.  He  arrives  at  the  conclusion  that 
two-thirds  of  the  cases  had  a  rheumatic  origin,  and  that  fright, 
strain,  and  other  injuries  are  to  be  .enumerated  among  the  list  of 
causes, or  rather,  as  the  writer  observes,  the  valve  not  being  healthy, 
these  special  causes  were  enough  to  aggravate  the  condition 
which  already  existed.  Slow  degenerative  changes  in  the  mitral 
valve  leading  to  stenosis  are,  I  think,  rightly  considered  not 
uncommon. :]:  In  the  case  of  two  girls  affected  with  mitral  ste- 
nosis, who  came  under  my  notice,  aged  respectively  18    xnd  17, 

*  Diseases  of  the  Heart  and  Aorta,  1875,  p.  315. 

t  Clinical  Lectures  on  Diseases  of  the  Heart  in  Childhood,  Med.  Times  and  Gaz., 
October,  1879,  p.  471. 

%  On  the  Etiology  of  Mitral  Stenosis,  St.  Earth.  Hosp.  Eep.,  vol.  siii,  p.  263. 


552  DISEASES   OF    CHILDREN. 

there  was  no  history  of  rheumatism,  nor  of  any  illness  that  could 
account  for  this  grave  cardiac  condition.  Of  the  ahove  eighty 
cases,  six  only  were  traceable  to  chorea.  Of  sixty-one  fatal  cases 
of  chorea  mentioned  by  Dr.  Hilton  Fagge,  there  were  only  two  in 
which  all  the  valves  of  the  heart  were  perfectly  healthy.* 

Treatment  of  Valvular  Diseases. — This  is  at  best  but  unsatisfac- 
tory. We  cannot  restore  the  injured  valve  in  its  integrity  ;  but 
we  can  foster  the  growth  of  hypertrophy,  and  in  some  fortunate 
cases  even  restore  the  ventricular  chamber  to  its  normal  size. 
The  symptoms  which  arise  as  a  consequence  of  these  organic 
changes  are  best  relieved  by  rest  and  the  avoidance  of  exercise 
and  excitement.  By  n:iaintaining  the  general  strength  and  guard- 
ing against  local  congestions  and  inflammatory  attacks,  we  may 
often  succeed  in  giving  a  fair  share  of  health  and  comfort  to  chil- 
dren ;  while  warm  clothing  (particularly  cotton-wool  or  flannel 
worn  over  the  chest),  nutritious  food,  and  active  aperients  will 
tend  to  keep  in  check  some  of  the  worst  symptoms,  as  dropsy, 
when  they  show  themselves.  If  coiigestion  of  the  lungs,  or  bron- 
chitis occur,  squill,  carbonate  of  ammonia,  belladonna,  strychnia, 
and  other  stimulating  expectorants  and  sinapisms,  will  be  indi- 
cated. 

When  the  heart  is  getting  weak  and  quick  in  mitral  disease, 
and  there  is  a  tendency  to  dilatation  of  the  right  cavities,  tincture 
of  digitalis,  administered  in  gradually  increasing  doses,  will  im- 
prove the  tone  and  fulness  of  the  pulse-beat,  reduce  the  frequency 
of  the  heart's  action,  and  cause  the  overdistended  cavities  to  con- 
tract more  vigorously  on  their  contents.  Instead,  therefore,  of 
blood  accumulating  in  the  heart  during  diastole,  a  larger  quantity 
is  expelled  at  each  contraction  of  the  ventricle.  Digitalis  has  been 
said  to  increase  the  discharge  of  urine,  but  there  is  some  doubt 
about  this  so  long  as  low  arterial  tension  remains  unaffected.  I 
carefully  measured  the  quantitj^  passed  in  two  cases  of  mitral 
regurgitation  in  children  with  dilatation  of  the  right  ventricle,  yet 
in  neitjier  was  there  an}'  appreciable  difference  in  the  amount 
passed,  nor  any  change  in  its  quality.  They  were  in  no  way  im- 
proved by  the  drug.  Traube  first  noticed  that  the  fall  of  the 
pulse-rate,  and  the  rise  of  arterial  tension  during  the  employ- 
ment of  digitalis,  are  attended  with  an  increased  amount  of 
urine. 

*  Reynolds's  System  of  Medicine,  Diseases  of  the  Valves  of  the  Heart,  vol.  iv,  p.  169. 


DISEASES   OF   THE   HEART.  553 

In  nearly  all  the  cases  in  which  I  have  given  digitalis  for  the 
heart  affections  of  children,  I  have  combined  it  with  iron,  and 
frequently  with  strychnia  also.  Iron  improves  the  quality  of  the 
blood  and  the  muscular  power  of  the  heart.  Digitalis  is  of  most 
value  in  simple  dilatation  from  debility  in  the  cardiac  muscle,  and 
in  both  forms  of  mitral  disease,  where  weakness  and  irregularity 
of  the  pulse  are  present.  It  may  be  given  with  advantage  in  dila- 
tation with  hypertrophy,  but  not  in  the  latter  form  of  heart  affec- 
tion alone.  Jf  nausea,  headache,  or  unsteadiness  of  pulse  should 
come  on  during  the  employment  of  digitalis,  the  drug  should  be 
intermitted  for  awhile. 

In  certain  rickety  children,  with  thoracic  deformity  and  twist- 
ing of  the  aorta,  hypertrophy  of  the  left  ventricle  is  early  devel- 
oped (Rokitansky),  and  in  some  cases  even  valvular  disease 
(Hilton  Fagge). 

Heart  cough  is  common  in  adults  in  the  failing  stages  of  heart 
disease,  and  is  usually  found  in  children  at  any  stage.  It  is  the 
result  of  congestion  of  the  pulmonic  circulation  ;  it  is  aggravated 
by  sedatives,  such  as  paregoric,  and  even  by  bromide  of  potassium  ; 
it  is  effectually  relieved  by  cardiac  tonics  like  digitalis  combined 
with  iron,  and  when  very  troublesome  it  is  well  to  put  the  patient 
to  bed  with  complete  rest  for  a  week  or  two. 

Hypertrophy  and  Dilatation. — Hypertrophy  of  the  heart,  which 
consists  of  an  increase  in  its  muscular  tissue,  is  owing  to  the 
greater  effort  which  the  organ  makes  to  overcome  the  obstruction 
of  blood  through  its  cavities. 

In  children  it  is  noticed  as  a  consequence  of  valvular  disease 
(especially  of  mitral  obstruction  or  regurgitation),  adherent  peri- 
cardium, emphysema  of  the  lungs,  and  chronic  renal  disease. 

The  physical  signs  are  heaving  impulse,  diffused  over  a  large 
space,  visible  to  the  eye,  and  raising  the  head  of  the  listener  when 
the  ear  is  applied  to  the  cardiac  region.  The  apex-beat  may  be 
seen  and  felt  between  the  sixth  and  seventh  ribs,  or  even  lower. 
The  pulse  is  full  and  strong  in  simple  hypertrophy,  but  if  accom- 
panied with  dilatation,  the  force  of  the  arterial  stream  is  con- 
siderably lessened.  The  heart's  sounds  are  dull  or  muffled,  and 
very  rarely  accompanied  by  murmur.  The  area  of  dulness  is  in- 
creased laterally,  and  to  the  left  of  the  sternum  when  the  left 
ventricle  is  involved.  When  pulmonary  emphysema  is  present, 
the  percussion  dulness  is  masked  through  the  margins  of  the  lungs 


554  DISEASES   OF   CHILDREN. 

overlapping  the  lieart.  In  rickety  subjects  the  prsecordial  region 
is  sometimes  rounded  or  prominent.  When  the  right  ventricle  is 
affected,  which  is  common  in  long-standing  cases,  there  is  epigas- 
tric pulsation,  and  the  margin  of  the  ventricle  can  be  felt  to  the 
left  of  the  ensiform  cartilage.  When  obstruction  exists  at  the 
mitral  orifice  (most  common  in  children),  the  left  auricle  becomes 
overfilled  with  blood  and  its  cavity  enlarged.  As  the  blood  accu- 
mulates in  the  pulmonary  circuit,  the  right  ventricle  gradually 
becomes  hypertrophied  and  dilated,  so  that  one  cavity  after 
another  is  more  or  less  affected.  In  mitral  disease,  the  left 
ventricle  may  remain  stationary  or  contract  in  size,  whilst  the  left 
auricle  is  enlarged ;  the  heart  is  globular  or  rounded  in  form,  and 
the  apex  chiefly  consists  of  the  right  ventricle. 

The  constitutional  symptoras  vary  according  to  the  mischief 
which  has  produced  the  hypertrophy.  The  walls  yield  and  the 
cavities  undergo  dilatation  when  the  heart  is  enfeebled  from  over- 
exertion. .  The  diaphragm  is  depressed  and  the  enlarged  heart 
tends  to  displace  the  lungs.  General  dilatation  of  the  cavities  is 
usually  seen  in  fat  and  feeble  adults  who  have  suffered  from 
menorrhagia,  chronic  bronchitis,  or  other  exhausting  ilhiess,  but 
in  children  it  is  most  frequently  the  result  of  mitral  regurgitation. 

Hypertrophy  of  the  heart,  associated  with  more  or  less  dilata- 
tion, is  a  common  attendant  on  chronic  kidney  disease.  The  left 
ventricle  is  most  frequently  involved.  It  arises  from  overgrowth 
of  muscle,  in  consequence  of  an  obstacle  in  the  smaller  arteries 
and  capillaries,  which  the  heart  is  striving  to  overcome.*  These 
vessels  become  contracted  and  cause  high  tension  in  the  vascular 
system,  because  the  structural  change  in  the  kidney  prevents  the 
elimination  of  urea,  and  other  products  of  metamorphosed  tissue. 
These  accumulate  in  the  blood  and  lead  to  thickening  of  the 
smaller  bloodvessels,  hypertrophy,  dropsical  effusion,  and  hoemor- 
rhages. 

The  general  signs  of  dilatation  are  a  frequent,  weak,  or  irregular 
pulse ;  the  veins  of  the  neck  are  often  prominent  when  the  right 
side  of  the  heart  is  affected,  and  if  the  case  proceeds  from  bad  to 
worse,  there  is  dyspnoea,  bloated  face,  anxious  countenance,  and 
finally  oedema  or  dropsy.  The  physical  signs  are  a  thumj)ing 
action  of  the  heart,  if  there  is  much  hypertrophy,  but  if  not,  those 

*  See  Chap.  XXIV,  On  Clironic  Desquamative  Nephritis,. 


DISEASES    OF    THE    HEAET.  555 

of  dilatation  maj  prevail,  and  then  the  impulse  is  weak,  short,  or 
tremulous.     The  first  sound  is  feeble  and  diffused. 

The  causes  of  dilatation,  pure  and  simple,  are  anaemia  and  gen- 
eral debility,  bronchitis  and  emphysema  of  the  lungs,  but  it  is 
usually  associated  with  valvular  diseases,  as  we  have  seen,  and 
then  the  sj'mptoms  vary  according  to  the  orifices  afliected,  and 
the  degree  of  hypertrophy. 

The  treatiiient  is  that  of  valvular  disease  of  the  heart,  with  which 
both  conditions  are  so  closely  associated. 

With  respect  to  malformation  of  the  heart,  the  septum  which 
divides  the  ventricles  is  occasionally  deficient,  and  the  two  cavities 
communicate.  The  foramen  ovale  is  also  large  and  open  in  some 
-cases,  or  the  folds  of  membrane  are  not  sufiiciently  developed  to 
close  the  orifice,  so  that  the  blood  passes  from  the  right  auricle 
into  the  left  auricle.  For  an  interesting  account  of  these  various 
irregularities,  the  reader  is  referred  to  Dr.  Peacock's  excellent 
work.* 

With  this  condition  there  is  often  contraction  at  the  orifice  of 
the  pulmonary  artery,  which  may  be  so  reduced  in  size,  as  barely 
to  admit  a  quill.  If  the  contraction  is  considerable,  and  the  fora- 
men ovale  large,  the  right  ventricle  is  small,  and  there  is  hyper- 
trophy and  dilatation  on  the  left  side. 

Cyanosis. — The  symptoms  of  this  peculiar  affection  are  a  blue 
tint  of  the  skin,  tongue,  and  lips,  and  a  general  coldness  of  the 
surface.  The  patient  is  subject  to  palpitation  and  violent  action 
of  the  heart,  faintness,  and  syncope  ;  the  pulse  is  feeble  and  some- 
times irregular,  and  bronchitis,  congestion  of  the  lungs,  haemoptysis, 
and  serous  eft'usions  are  apt  to  suvervene,  when  the  disorder  is  of 
any  considerable  duration. 

Among  the  physical  signs,  the  existence  of  a  murmur  is  gen- 
erally to  be  detected  over  the  point  of  communication.  In  the 
following  case  there  was  no  bruit. 

]Sr.  C ,  aged  3,  was  admitted  into   the   Samaritan  Hospital 

under  my  care,  October  22d,  1877,  with  well-marked  symptoms  of 
cyanosis.  The  mother  attributed  the  symptoms  to  the  shock  of 
the  gunpowder  explosion  in  Eegent's  Park,  but  the  child  had 
8ufi:ered  from  whooping  cough  shortly  after  birth,  and  at  the  time 
of  the  explosion  had  a  severe  cough.  On  admission,  the  counte- 
nance was  deeply  congested,  and  the  lips  were  of  a  claret  hue;  the 

*  On  Malformations  of  the  Heart,  2d  edit.,  1866,  p.  107. 


656  DISEASES    OF    CHILDRE]^. 

swollen  eyes  stood  forward  in  their  sockets,  and  the  eyelids  were 
cedematous ;  the  feet  and  hands  lacked  warmth,  and  presented  the 
same  venosity  as  the  face.  The  child  was  constantly  turning  and 
twisting  about  in  bed  to  obtain  ease,  and  when  fretful  and  irrit- 
able was  darkest  in  color.  Sometimes  she  would  lie  on  her  face, 
sleeping  for  hours  together,  and  resenting  any  interference.  The 
pulse  was  140,  contracted  and  small ;  respirations  short  and  shallow. 
The  chest,  both  in  front  and  behind,  was  resonant.  The  bowels 
were  regular;  urine,  sp.  gr.  1018,  fair  in  quantity,  pale,  slightly 
clouded,  non-albuminous,  and  of  neutral  reaction. 

'No  murmur  could  be  heard  over  any  of  the  heart's  orifices,  the 
sounds  being  distinct  throughout  the  cardiac  region,  as  well  as 
posteriorly.  The  action  resembled  an  excited  and  palpitating 
heart,  and  was  much  worse  at  one  time  than  at  another.  The  tem- 
perature on  admission  was  100°,  at  the  end  of  ten  days  it  fell  to 
98.4°,  when  the  mother  took  the  child  out  of  the  hospital.  Death 
took  place  a  month  afterwards. 

The  causes  are  a  communication  between  the  auricles,  or  a  single 
auricle  and  ventricle,  or  narrowing  of  the  pulmonary  artery,  and 
mitral  orifice.  Opinions  are  much  divided  on  the  causes  which 
induce  this  discoloration  of  surface.  The  case  of  a  male  infant, 
nine  months  old,  is  recorded  by  Dr.  Caj'ley,  in  which  the  aortic 
valves  were  extensively  diseased.  From  birth  the  child  was  short 
of  breath,  and  when  first  brought  for  treatment  there  was  dyspnoea, 
but  no  cyanosis.  The  cardiac  impulse  was  much  increased,  and 
there  was  a  loud  systolic  murmur  over  the  cardiac  region.  Before 
death  there  was  some  degree  of  cyanosis.  "  On  post-mortem  ex- 
amination the  left  ventricle  was  found  much  hypertrophied.  The 
aortic  orifice  was  much  constricted,  and  the  valves  were  covered 
with  large,  firmly  adherent,  fibrous  vegetations,  evidently  of  long 
standing."*  It  has  been  attributed  by  some  authorities  to  general 
congestion  of  the  venous  system  from  obstruction  at  the  pulmo- 
nary orifice  (pulmonary  stenosis),'f  by  others  to  the  admixture  of 

*  Path.  Trans.,  1875,  vol.  xxvi,  p.  33. 

t  Dr.  Peacock  showed  a  specimen  before  the  Pathological  Society  (October  15th, 
1878)  of  stenosis  of  the  pulmonary  artery  from  disease  of  the  valves,  which  he  believed 
to  be  congenital.  The  boy  was  13  years  of  age,  always  livid,  and  never  strong. 
Dyspnoea  and  increased  lividity  came  on  a  short  time  before  he  was  admitted  into 
hospital.  "  There  was  a  loud  double  murmur  over  the  pulmonary  cartilage,  and  a 
distinct  thrill."  The  patient  was  dropsical  and  died.  After  death  the  right  ventricle 
was  found  dilated  and  hypertrophied,  and  the  orifice  of  the  i^ulmonary  artery  narrowed 
and  funnel-shaped. 


ON    DISEASES    OF    THE    BRAIN.  557 

venous  with  arterial  blood  ;  whilst  there  are  those  who  contend  for 
the  presence  of  venous  blood  in  the  arteries  and  general  circula- 
tion, as  the  true  explanation  of  the  lividity.  It  has  been  stated 
bj  Dr.  Stille  that  cyanosis  may  exist  without  the  intermixture  of 
the  currents  of  blood,  and  that  intermixture  may  take  place  with- 
out any  cyanosis.  M.  Yalleix  does  not  think  that  a  communica- 
tion between  the  rio-ht  and  left  cavities  of  the  heart  is  a  certain 
proof  of  cyanosis.  It  is,  however,  generally  regarded  as  due  to 
venous  congestion  and  the  mixture  of  arterial  with  venous  blood. 
The  latter  hypothesis  seems  the  most  correct,  for,  as  Dr.  Walshe 
truly  remarks,  the  most  intense  venous  obstruction  may  exist  in 
the  adult  without  producing  cyanosis.  Dr.  Peacock  regards  cya- 
nosis as  due  to  congestion  of  the  venous  system.  Though  it  would 
seem  difficult  to  determine  the  exact  condition,  it  is  not  improb- 
ably due  in  some  instances  to  fulness  of  the  venous  radicles,  and 
imperfect  aeration. 

The  prognosis  is  most  unsatisfactory.  The  child  may  die  from 
syncope,  or  in  a  lit  of  coughing  and  urgent  dyspnoea  from  conges- 
tion of  the  luno;s.  Instances  are  mentioned  of  adult  life  beino- 
attained,  "and  in  one  case,  recorded  by  Louis,  the  age  of  fifty- 
seven  was  reached."* 

The  treatment  consists  in  rest,  pure  air,  and  warmth,  careful 
diet,  and  attention  to  the  digestive  organs. 


CHAPTER  XLIL 

ON    DISEASES    OF    THE    BRAIN. 


Simple  Meningitis.  Pia  aeachnitis.  Encephalitis  (Phrenitis  of  Cullen). 
Inflammation  op  the  Bbain  and  Membranes:  Its  proneness  to  attack  the  con- 
vexity of  the  cerebral  hemiqjherea — Simple  meningitis — A  less  frequent  disease  than  the 
tubercular  form.  Causes:  Exposure  to  cold,  heat,  and  privation — Oeneral  debility — 
Traumatic  origin — Effect  of  otorrhoea  and  foreign  bodies  in  the  ear  in  setting  up  menin- 
gitis— Specific  fevers — Blood-poisoning.  Symptoms  :  Headache  and  vomiting — Heat 
of  head — Quick  pulse  and  fever — Convulsions — Delirium — Loss  of  speech — Character 
of  the  ptdse  and  respiration — Elevation  of  temperature — Coma-^Difficulties  in  forming 
a  differential  diagnosis — Ophthalmoscopic  signs.  Treatment:  To  lessen  vascularity 
in  the  inflamed  part  by  depressing  the  circulation  ivith  aconite  and  tartar  emetic,  to 
soothe  and  calm  the  excited  and  inflamed  encephalic  centres — Iodide  of  potassium  and 

*  Hooper's  Vade  Mecum,  by  Dr.  Gny  and  Dr.  Harley,  1874,  p.  425. 


558  DISEASES    OF   CHILDREN. 

hydrate  of  chloral —  Use  of  mercury  as  a  purgative,  and  to  increase  biliary  discharge — 
Continuous  application  of  cold  to  the  head  — Leeches — Salines — Bromide  of  potassium 
■ — Tonics — Stimulants  and  counter-irritation  in  coma.  Tubercular  Meningitis  or 
Acute  Hydrocephalus:  Pathology  of  the  affection  and  common  seats  of  the  miliary 
granulations  which  excite  inflammatory  and  degenerative  changes  in  the  brain  and  ven- 
tricles— Their  size,  structure,  and.  composition — Distinctive  pathological  characters  of 
tubercular  meningitis.  Symptoms  :  Gradual  impairment  of  the  general  health — In- 
sidious character  of  the  vomiting — Constipation — Albuminous  urine — State  of  the  pulse 
and  pupils — Unsteadiness  and  irregularity  in  the  force  and  frequency  of  the  respiration 
— Hydrocephalic  sighs — Relation  between  the  pulse,  respiration,  and  temperature — Head- 
ache often  mistaken  for  neuralgia — Hemiplegia  and  paralysis — Cases  of  tubercular 
meningitis — Post-mortem  appearances.  Chronic  Basilar  Menij^'gitis.  Diagnosis  : 
Use  of  the  ophthalmoscope  in  the  detection  of  intracranial  disease.  Treatment  : 
General  hygienic  rules  to  be  strictly  observed  in  the  threatening  stage — Risk  in  hastily 
healing  active  eruptions  of  the  scalp — Antiphlogistic  remedies  in  the  early  stages — Im- 
portance of  calomel  where  the  bodily  powers  are  not  too  much  reduced — Cold  to  the  head 
— Iodide  and  bromide  of  potassium — Occasional  value  of  morphiato  insure  rest  and  sleep. 
Chronic  and  Congenital  Hydrocephalus:  Meaning  of  the  terms  and  situation 
of  the  fluid  in  the  brain  and  membran"S — Pathology — Shape  and  size  of  the  head — Com- 
jMsition  of  the  fluid — Alteratives — Mercurial  inunction — Leeches — Tonics — Compres- 
sion—  Puncture. 

Simple  Meningitis. — Inflammation  of  the  pia  arachnoid  is  now 
known  as  leptomeningitis.  The  arachnoid  and  pia  mater  are  in 
such  close  relation  to  each  other  that  it  is  not  always  possible  to 
separate  them  in  the  morbid  changes  to  which  they  are  liable 
under  the  inflammatory  process ;  neither  are  we  clinically  able  to 
describe,  with  anything  approaching  exactness,  the  symptoms  of 
inflammation  of  the  membrane  apart  from  inflammation  of  the 
cerebral  mass  itself:  "There  is  no  symptom  which,  during  life, 
could  help  to  distinguish  between  inflammation  affecting  the  pia 
mater  and  inflammation  involving  the  arachnoid  alone;  and  as 
the  treatment  in  either  case  would  be  the  same,  there  would  be  no 
practical  advantage  gained  by  such  distinction."*  I  do  not  hap- 
pen to  have  met  with  an  instance  in  whidi  the  arachnoid  mem- 
brane has  been  inflamed  and  the  pia  mater  not  implicated  also  [pia 
arachnitis);  but  cases  of  the  kind  are  recorded  in  the  history  of 
medicine.  If  the  meningitis  has  been  due  to  traumatic  causes, 
then  the  dura  mater  is  involved  in  the  inflammatory  process,  and 
a  circumscribed  patch  of  flbrinous  exudation  or  purulent  matter 
ma}'  be  seen  lying  upon  it.  According  to  Dr.  Greenfield,  the  pia 
mater  is  "primarily  and  chiefly  aftected"  in  secondary  meningitis, 

*  Simple  Meniogitis,  by  J.  Spence  Il:imskill,  M.D.,  Reynolds's  System  of  Medicine, 
vol.  ii,  p.  2G7. 


ON    DISEASES    OF    THE    BRAIN.  559 

or  that  arising  from  contaminated  blood,  whilst  "in  traumatic 
meningitis,  the  dura  mater  and  arachnoid,  or  the  arachnoid  itself, 
is  chiofl}'  involved."*  . 

"Dura-arachnitis,  or  pachymeningitis,  with  its  effusion  between 
the  arachnoid  surfaces,  is  an  afiection  intimately  connected  with 
disease  of  the  dura  mater,  and  arises  from  some  external  cause ; 
whilst  the  effusion  beneath  the  arachnoid,  and  immediately  in 
connection  with  the  cerebral  substance,  has  its  cause  within,  and 
constitutes  the  idiopathic  inflammation  of  the  membranes.  In 
ordinary  idiopathic  meningitis,  the  effusion,  be  it  lymph  or  pus,  is 
poured  out  from  the  pia  mater,  a  structure  which  consists  of  a 
niost  rich  plexus  of  vessels,  held  together  by  delicate  areolar  tissue, 
following  all  the  inequalities  of  the  convolutions,  and  lying  beneath 
the  level  surface  of  the  visceral  arachnoid  membrane,  with  which 
it  is  connected  by  fine  filaments,  forming  a  delicate  texture  that 
crosses  the  subarachnoid  surface-"f 

The  anatomical  appearances  of  simple  or  acute  meningitis,  then, 
are  great  hyperremia  and  vascularity  of  the  pia  mater  and  arach- 
noid, with  the  effusion  of  serum,  or  the  exudation  of  lymph,  or 
seropurulent  matter,  or  pus  itself,  in  patches  of  variable  size,  oc- 
cupying the  subarachnoidean  space,  dipping  into  the  sulci,  and 
obliterating  the  convolutions. 

When  the  dura  mater  is  removed,  the  membrane  beneath  is  seen 
to  be  vascular  and  congested,  either  generally,  which  is  very  rare, 
or  in  patches  over  the  superficial  portion  of  the  hemispheres.  It 
sometimes  presents  a  glistening  whitish  look,  and  is  thin  and  al- 
most transparent ;  or  it  is  thicker,  with  an  opalescent  or  faint 
milky  appearance.  Sometimes  it  is  greenish-yellow,  and  does  not 
exceed  the  thickness  of  a  line.  When  the  membrane  is  removed, 
distended  vessels  and  inflammatory  exudation  may  be  seen  dipping 
down  between  the  convolutions  and  depressions  of  the  brain ;  but 
in  many  cases  the  congestion  is  not  more  than  may  be  observed  in 
children  who  have  died  of  fever  or  some  other  acute  disease  in 
which  the  brain  has  only  shown  signs  of  exhaustion  daring  life. 
Occasionally  the  under  surface  of  the  arachnoid  is  covcied  with 
exudation,  or  false  membrane,  which  contracts  adhesions  between 
it  and  the  brain.  This  transparent  fluid  may  also  be  seen  in  the 
ventricles,  varying  from  one  drachm  to  an  ounce  or  njore;  and  an 

*  St.  Thomas's  Hospital  Keports,  vol.  viii,  1877,  p  145. 

t  Pathological  Anatomy,  by  Wilks  and  Moxon,  1875,  p.  208. 


560  DISEASES   OF   CHILDREN. 

opaque,  gelatinous  fluid  may,  in  some  cases,  be  observed  at  the 
base  of  the  brain.  Purulent  matter  is  an  occasional  but  rare  oc- 
currence. In  some  cases  that  have  set  in  suddenly  and  terminated 
in  a  few  days,  the  vessels  of  the  scalp  will  be  found  distended  with 
blood,  and  the  brain  and  membranes  turgid;  lymph  may  be  seen 
scattered  over  the  convolutions,  so  as  nearly  to  conceal  them,  and 
the  substance  of  the  brain  is  generally  soft  and  vascular,  whilst 
the  serum  in  the  ventricles  is  turbid  or  purulent.  Some  of  these 
cases  have  received  the  name  of  "water-stoke"  by  Golis. 

Simple  leptomeningitis  generally  selects  the  convexity  of  the 
cerebral  hemispheres,  whilst  the  base  of  the  brain  is  the  chosen 
seat  of  the  exudation  in  the  tubercular  variety.  The  convexity 
of  the  anterior  lobe  is  more  frequently  affected,  but  the  exudation 
may  run  along  the  surface  of  the  brain  posteriorly,  and  attack  the 
inferior  aspect  of  the  cerebellum  and  the  medulla  oblongata.  It 
may  involve  the  upper  portion  of  the  spinal  cord,  and  be  surounded 
by  a  considerable  quantity  of  turbid  serum.  The  lateral  portions 
of  the  hemispheres,  and  still  more  rarely  the  under  surface,  are 
more  affected  in  this  form  of  meningitis ;  at  the  same  time  the 
extent  and  locality  of  the  inflammation  are  variable,  and  the 
symptoms  are  much  more  acute  in  some  cases  than  in  others.  The 
disease  has  many  points  which  resemble  tubercular  meningitis ; 
but  it  is  not  so  common,  and  is  less  frequently  met  with  in  children 
than  that  aft'ection.  It  occurs  occasionally  among  infants,  but  is 
very  rare  after  the  age  of  two  years.  I  have  seen  two  cases  in 
single  young  women ;  one  seventeen,  the  other  twenty  years  of 
age.  Exposure  to  cold  and  privation  seemed  to  be  the  cause  in 
the  younger  case,  and  debility  and  an^Bmia  after  typhoid  fever  the 
cause  of  the  other.  Simple,  or  idiopathic  meningitis,  not  arising 
from  local  irritation  or  injury,  tumors  or  other  morbid  growths 
in  the  brain  or  its  membranes,  must  be  considered  as  a  rare 
disease. 

Causes. — Injuries  of  the  head  may  set  up  meningitis  in  children. 
A  young  lady,  aged  11,  previously  in  good  health,  told  her  mother 
that  she  had  had  a  fall  on  returning  from  school.  She  then  ate  a 
good  dinner,  but  was  sick  in  the  evening;  had  severe  headache 
and  fever  next  day  ;  the  pain  began  on  the  left  side  of  the  head, 
extending  in  a  few  hours  to  the  opposite  side,  and  along  the  upper 
part  of  the  spine.  She  died  rather  suddenly  little  more  than 
forty-eight   hours  after  the   fall.     The  arachnoid   was  dry  and 


ON    DISEASES    OF    THE    BRAIX.  561 

rather  opaque,  with  numerous  3'ello wish-white  patches  between  it 
and  the  pia  mater.  The  vessels  on  the  surface  of  the  brain  were 
much  distended.  No  disease  of  either  tympanum  or  petrous 
bone  could  be  detected.  Dr.  Crisp  was  "  disposed  to  think  that 
the  fall,  which  might  have  been  more  severe  than  at  first  supposed," 
w^as  the  cause  of  the  meningitis,  which  was  remarkably  localized 
(as  the  brain-substance  was  healthy)  and  unusually  rapid.*  Men- 
ingitis may  ensue  from  concussion  of  the  brain  at  once,  or  follow 
it  after  weeks  or  even  months,  if  the  child  has  attempted  to  exert 
its  brain  too  soon  after  apparent  recovery.  Immoderate  reading, 
extremes  of  heat  and  cold,  checked  eruptions  about  the  head  and 
face,  are  also  to  be  enumerated  among  the  causes.  A  frequent 
cause  is  the  extension  of  the  inflammation  from  the  internal  ear. 
"  Otitis  interna  is  probably  often  the  unsuspected  cause  of  menin- 
gitis, for  it  is  not  necessary  that  external  discharge  or  obvious 
caries  of  the  bone  should  occur,  a  far  slighter  degree  of  inflamma- 
tion sufficing  to  set  up  the  disease. "f  "  Sometimes  the  symptoms 
of  otitis  distinctly  precede  those  of  meningitis.  Sometimes  the 
meningitis  sets  in  without  any  precedent  symptoms  of  otitis ;  and 
when  this  is  the  case,  sometimes  the  symptoms  of  otitis  show 
themselves  in  the  course  of  the  meningitis  ;  sometimes  the  otitis 
is  latent  and  undiscoverable  throughout.":};  But  long-standing 
otorrhoea,  which  has  led  to  disease  of  the  petrous  portion  of  the 
temporal  bone,  the  exanthematous  fevers,  and  especially  scarlet 
fever,  are  causes  of  the  aftection.  If  in  a  child  so  suffering,  delirium, 
high  fever,  convulsions,  or  coma  result,  we  may  suspect  the  super- 
vention of  meningitis.  Erysipelas  probably  induces  the  complaint 
in  a  similar  manner.  A  case  is  recorded  of  fatal  meningitis  in  a. 
child  which  was  induced  by  the  rough  measures  which  were 
employed  to  extract  a  stone  from  the  ear.§  It  may  occur  as  an 
epidemic  in  conjunction  with  inflammation  of  the  spinal  meninges, 
constituting  cerebro-spinal  meningitis. ||  The  action  of  the  poison 
is  directed  to  the  meninges,  just  as  the  blood  infection  of  septi- 

*  Trans.  Path.  Soc,  vol.  xxvii,  p.  28. 

t  On  Simple  Meningitis,  by  W.  S.  Greenfield,  M.D.,  St.  Thomas's  Hospital  Eeports, 
1877,  p.  143. 

X  Meningitis  and  Otitis  Interna,  St.  Bartholomew's  Hospital  Keports,  vol.  viii,  p.  25. 

g  Contributions  to  Aural  Surgery,  by  W.  B.  Dalby,  F.R.C.S.,  M.B.,  Lancet,  Sept. 
25th,  1875,  p.  447. 

II  Meigs  and  Pepper,  Diseases  of  Children,  p.  509. 

36 


5 62  DISEASES  OF  childee:n". 

cfemia,  albuminuria,  syphilis,  rlieimiatisra,  or  the  specific  fevers, 
may  originate  meningitis  or  pleurisy,  or  any  other  form  of  serous 
inflammation.  Simple  meningitis  may  follow  whooping-cough  and 
bronchopneumonia. 

Simple  meningitis,  when  it  does  not  result  from  traumatic  causes, 
must  not  be  cousidered  beyond  the  possibility  of  recovery.  The 
exudation  poured  out  under  the  inflammatory  process  slowly  con- 
tracts into  a  fibrous  structure,  and  the  pia  mater  into  a  whitish 
firm  membrane,  adherent  to  the  brain  on  one  side  and  the  under 
surface  of  the  arachnoid  on  the  other.  This  disease  may  begin 
with  acute  and  active  symptoms,  and  in  the  course  of  two  days 
attains  its  climax.  Strong  and  healthy  children  are  more  frequently 
attacked  than  those  who  inherit  delicate  constitutions.  Some  cases 
set  in  slowl}"  and  insidiously,  and  the  most  careful  and  experienced 
practitioner  may  be  deceived  as  to  what  is  about  to  happen.  This 
difl:erence  in  the  symptoms  is  chiefly  owing  to  the  circumstance 
that  the  disease  may  come  on  primarily,  or  in  consequence  of  other 
diseases.  In  the  latter  case  there  may  be  nothing  but  great 
depression  of  the  vital  powers,  and  eventually  paralj-sis,  while 
where  it  is  primary,  it  is  usually  ushered  in  by  rigors  and  heat, 
with  high  temperature,  and  a  quick  pulse. 

One  reason  why  meningitis  is  apt  to  be  overlooked  in  these  cases 
arises  from  the  absence  of  the  whole  train  of  symptoms  which  are 
said  to  belong  to  that  state.  The  symptoms  are  more  developed 
in  some  cases  than  in  others;  but  it  must  not  be  supposed  that  we 
are  not  dealing  with  meningitis  because  a  few  of  the  symptoms 
only  are  present,  and  have  not  succeeded  one  another  in  any 
regular  order.  Each  case  has  its  separate  commencement  and 
class  of  symptoms — it  may  have  a  tardy  and  obscure  beginning, 
of  days  and  even  weeks,  or  be  sudden  and  fierce  in  its  develop- 
ment. If  a  child  with  febrile  symptoms  has  headache,  nausea, 
and  vomiting,  and  brings  up  bile,  we  must  be  careful  lest  we  direct 
our  attention  to  the  stomach,  and  neglect  the  head.  If  the  belly  is 
soft,  and  free  from  tenderness  and  distension,  the  bowels  costive, 
and  the  tongue  clean,  the  signs  are  of  still  more  ominous  omen. 
If  thej'^  vanish  for  a  time  and  recur  again,  and  there  has  been  no 
indiscretion  or  irregularity  of  living  to  account  for  it,  we  must 
exercise  caution  in  the  expression  of  an  opinion.  There  are  cases 
of  cerebral  disease  to  be  met  with  in  young  children,  preceded  by 
such  insidious  indications  of  failing  health  that  the  possibility  of 


ON   DISEASES   OF  THE   BRAIX.  563 

brain  affection  is  overlooked  altogetlrer,  and  the  symptoms  are 
either  attril)uted  to  fever,  to  some  pulmonary  disorder,  or  they  are 
60  obscure  that  the  practitioner  is  unable  to  form  any  diagnosis. 
At  this  early  period  it  is  doubtful  whether  the  symptoms  are  due 
to  any  morbid  change  in  the  membranes  or  cerebral  tissue.  It  is 
indisputable  that  some  of  the  symptoms  which  spring  from  eccen- 
tric sources  of  irritation,  propagate  an  indirect  influence  to  the 
brain,  and  give  them  the  semblance  of  issuing  direct  from  the 
brain  itself.  Moreover,  any  long-continued  illness  in  a  badly 
nourished  child  exposes  him  to  the  danger  of  cerebral  disease, 
especially  if  he  is  the  offspring  of  tubercular  or  syphilitic  parents. 
Approaching  dentition  renders  him  more  susceptible  through  the 
irritation  it  excites — a  tedious  attack  of  diarrhoea  still  further 
impoverishes  the  brain,  and  reduces  the  general  health.  Croup, 
bronchitis,  or  any  other  acute  disease,  will  be  equally  powerful  in 
disturbing  the  equilibrium  of  the  circulation,  and  fretting  the 
nervous  system  till  it  culminates  in  an  actual  outbreak.  Watch 
the  out-patient  department  of  any  London  hospital  where  there 
are  a  fair  number  of  children,  and  we  shall  often  find  that  a  child 
who  is  recovering  from  diarrhoea,  or  has  an  eruption  of  the  scalp^ 
or  suffers  from  general  debility,  or  has  been  exposed  to  great  heat, 
and  the  scorching  rays  of  the  sun,  is  suddenly  seized  with  a  fit  of 
convulsions,  followed  by  inflammation  of  the  brain. 

Symptoms. — In  most  examples  of  simple  meningitis,  languor, 
drowsiness,  and  symptoms  of  excitement  will  manifest  themselves 
for  some  days  before  the  accession  of  more  dangerous  symptoms. 
Severe  headache  is  one  of  the  most  constant  and  persistent 
symptoms.  It  may  be  so  acute  as  to  cause  the  child  to  utter  a 
piercing  cry.  The  eyes  have  a  wild  and  glistening  look,  the 
pupils  are  contracted,  and  the  child  shuns  the  light.  Strabismus 
of  one  or  both  eyes  is  sometimes  present,  the  vessels  of  the  con- 
junctivos  are  injected,  and  the  temporal  arteries  throb.  The  pulse 
is  frequent,  sharp,,  and  incompressible.  It  is  sometimes  slow  at 
the  commencement  of  the  illness,  but  accelerated  after  food,  or 
any  attempt  to  examine  the  child,  The  breathing  may  be  soft 
and  regular  at  this  stage.  The  child  may  draw  a  deep  sigh  now 
and  then,  and  move  its  head  about  on  the  pillow  as  if  in  uneasy 
sleep.  The  head  is  hot,  and  the  veins  about  the  temples  swollen 
and  dilated  in  some  cases,  whilst  in  others  the  face  presents  a 
pallid  look,  alternating  with  an  occasional  flush  over  the  malar 


564  DISEASES   OF  CHILDEEIS'. 

bones  and  upper  portion  of  the  cheeks.  Then  follow  wandering 
and  delirium  at  night,  with  intervals  of  consciousness  during  the 
day,  to  be  shortlj^  succeeded  bj  convulsions,  or  increasing  ex- 
haustion and  death.  The  temperature  is  generally  elevated, 
though  it  is  not  always  so  in  the  early  stages  of  meningitis.  In 
some  cases  it  runs  exceedingly  high.  It  may  vary  three  or  four 
degrees  during  the  day  when  there  are  relapses  and  exacerbations. 
Thus  in  the  morning  it  may  be  normal,  and  by  the  evening  reach 
103°  or  even  106°,  esj)eciaHy  if  the  case  has  succeeded  scarlet 
fever,  otorrhoea,  or  pneumonia.  The  tongue  is  natural,  or  white 
and  moist ;  and  thirst  is  frequently  complained  of  whilst  intelli- 
gence remains  clear.  Vomiting,  of  sympathetic  origin,  is  very 
often  present,  and  when  associated  with  meningitis  is  usually 
accompanied  by  constipated  bowels. 

Some  cases  set  in  with  a  paroxysm  of  convulsions,  especially  in 
very  young  children,  which,  according  to  Andral  and  Sir  Thomas 
"Watson,*  denote  greater  certainty  of  cerebral  inflammation  than 
delirium.  But  cases  so  beginning  have  shown,  after  death,  the 
brain-substance  to  be  free  from  inflammation  altogether,  and  no 
lymph  in  the  arachnoid  cavity.  Both  Andral  and  Abercrombie 
have  seen  instances  in  which  loss  of  speech  was  the  first  indication 
of  the  illness.  In  the  case  of  a  child,  aged  three  years,  whom  I 
attended,  the  first  symptom  to  direct  attention  to  the  brain  was 
the  sudden  loss  of  speech,  or  rather  an  imperfect  guttural  articu- 
lation. This  was  followed  in  the  course  of  a  few  days  by  headache, 
pyrexia,  and  vomiting  ;  quick  pulse ;  ptosis  and  partial  hemiplegia, 
and  no  amendment  in  the  power  of  speech.  The  urine  was  slightly 
albuminous.  AYhen  the  little  child  was  asked  a  simple  question  it 
moved  its  lips  sluggishlj^,  and  the  tougae  performed  a  peculiar 
rolling  motion,  but  nothing  like  an  articulately  pronounced  word 
could  be  uttered.  When  nausea  and  vomiting  are  the  earliest 
symptoms  the  inflammation  is  said  by  Sir  Thomas  Watson  to  have 
originated  in  the  substance  of  the  brain ;  when  convulsions  have 
attended  the  outbreak  of  the  symptoms,  it  has  originated  in  the 
arachnoid  or  pia  mater,  and  when  early  and  fierce  delirium  are 
present,  the  gray  portions  of  the  convolutions  or  superficial  parts 
of  the  hemispheres  are  first  invaded.  This  is  highly  probable,  and 
it  accords  with  my  experience  that  delirium  is  a  striking  feature 
of  irritation  or.  excitement  of  the  membranes,  whilst  convulsions 

*  Practice  of  Physic,  vol.  i,  p.  395,  4th  edit.,  1857. 


ON    DISEASES   OF   THE   BRAIN".  565 

are  oftener  associated  with  cysts  and  deepseated  tumors,  or  such 
changes  as  occur  at  the  hase  of  the  brain  in  some  forms  of  chronic 
and  tubercular  meningitis. 

In  cases  less  violent  than  those  I  have  described,  some  increase 
of  irritability,  shyness  of  manner,  uneasy  sleep,  headache  and  sick- 
ness, will  on  inquiry,  in  most  instances,  be  found  to  have  preceded 
an  actual  outbreak.  In  yoang  children  all  these  symptoms  are 
common  to  intestinal  derangement,  and  hence  they  increase  the 
difficulty  of  forming  a  differential  diagnosis.*  Headache  and  sick- 
ness are  among  the  earliest  symptoms,  inviting  our  attention  to 
the  brain  as  the  organ  primarily  at  fault.  If  these  two  symptoms 
were  absent  we  might  very  naturally  overlook  the  disease.  As 
the  disease  advances  towards  a  fatal  termination  the  breathing  is 
irregular  and  often  sighing ;  it  is  sometimes  so  tranquil  that  it 
seems  to  have  suddenly  stopped.  The  expression  is  bewildered 
and  confused,  and  the  eyes  are  fixed  and  staring.  The  pupils  may 
be  of  equal  size,  even  if  convulsions  and  restlessness  are  present ; 
but  if  the  child  becomes  unconscious,  and  there  are  any  symptoms 
of  paralysis,  then  one  or  both  may  become  widely  dilated  and  in- 
sensitive to  light.  When  comatose  symptoms  occur  at  a  later 
-Btage  of  the  illness,  the  pupils  become  dilated,  or  one  is  more  di- 
lated than  the  other,  and  there  may  be  squinting  and  partial  ptosis. 
The  temperature  is  at  first  increased,  and  in  the  later  stages  of 
the  disease  lowered,  ranging  between  94°  and  104°. 

The  condition  of  the  eyes,  as  revealed  by  the  ophthalmoscope, 
is  referred  to  in  the  next  chapter,  but  I  may  here  quote  Dr.  Green- 
field's experience:  "  Optic  neuritis  is  absent  in  the  larger  number 
of  cases  of  acute  meningitis  of  the  vertex,  whether  simple  or 
tubercular,  if  the  cases  in  which  there  is  a  tubercular  infiltration 
or  tumor,  or  a  coincident  basal  meningitis  are  excluded.  Where 
any  affection  of  the  eye  exists  in  meningitis  of  the  vertex,  it  is 
more  commonly  only  swelling  of  the  papilla,  or  choked  disk,  and 
only  reaches  any  further  stage  in  the  cases  of  localized  meningitis 
(oftenest  syphilitic)  which  run  a  subacute  course."t  In  a  case  of 
meningitis  complicated  with  otorrhoea,  in  which  after  death  the 
membranes  were  found  thick  and  opaque,  the  optic  nerve  was 
covered  with  a  whitish  cloud  partially  hiding  the  vessels,  and 
there  was  optic  neuritis  from  congestion  of  the  vessels  along  the 

*  See  Chap.  VIII,  On  Typhoid  Fever. 

t  St.  Thomas's  Hospital  Eeports,  1877,  p.  160. 


566  DISEASES    OF    CHILDEEX. 

optic  nerves.  (Gee,  op,  cit.)  The  pulse  may  now  become  so  rapid 
that  it  cannot  be  counted,  and  the  heart's  action  may  be  feeble  and 
tumultuous.  The  radial  pulse  is  not  to  be  detected  at  each  flut- 
tering cardiac  contraction.  Instead  of  the  fierce  delirium  of  the 
early  stage,  the  child  may  dow  be  observed  to  roll  its  head  from 
side  to  side,  and  there  is  flushing  of  one  or  both  cheeks,  as  is  fre- 
quent in  the  evening  paroxysm  of  typhoid  fever  in  young  subjects. 
Add  to  this  catalogue  of  sj-mptoms  the  presence  of  stertor,  and 
indications  of  gradual  eftusion  going  on  at  the  base  of  the  brain, 
and  we  complete  the  description  of  a  hopeless  condition.  The 
belly  is  sunken  and  retracted,  the  motions  are  dark  and  offensive  ; 
and  as  the  disease  advances  they  may  be  passed  in  the  bed  uncon- 
sciously. In  those  exceptional  cases  that  recover,  signs  of  improve- 
ment either  set  in  early,  or  the  disease  does  not  reach  the  severe 
stasce  I  have  been  describiuo;.  It  is  more  chronic  and  obscure,  and 
does  not  run  on  with  the  velocity  of  the  fatal  forms. 

Some  cases  recover,  under  great  care  and  patience,  if  the  disease 
has  not  set  in  with  fierce  delirium  or  convulsions,  and  the  fever  is 
moderate.  But  death  at  the  end  of  a  week  is  the  rule.  In  some 
cases  the  disease  terminates  fatally  in  less  than  forty-eight  hours. 
The  general  intelligence  is  defective  in  the  very  few  cases  I  have 
seen  get  well,  and  the  memory  and  power  of  attention  are  im- 
paired. Whether  the  brain  is  ever  again  able  to  bear  full  intel- 
lectual tension  is  an  open  question  ;  but  morbid  anatomy  reveals 
nothing  incompatible  with  it  in  the  case  of  young  and  otherwise 
healthy  children.  I  have  met  with  two  cases  of  recovery  from  a 
subacute  form  of  simple  meningitis  in  children  in  whom  the  tem- 
perature at  no  period  of  the  illness  exceeded  the  normal  point, 
thouo-h  the  head  became  larsre  in  both  cases  from  eff'usion.  In 
one  of  the  cases  there  was  hemiplegia,  strabismus,  and  evacuations 
were  passed  unconsciously.  The  morbid  changes  in  the  brain  and 
membranes  must  have  been  unusuallj'  slow  and  chronic. 

Treatment. — A  child  suffering  from  acute  meningitis  should  be 
seen  at  least  every  four  or  six  hours,  to  watch  the  effect  of  the 
progress  of  the  disease  on  the  one  hand,  and  the  action  of  the 
remedies  on  the  other.  The  principle  of  treatment  is  compara- 
tively simple.  It  should  combine  two  elements.  1.  To  lower  the 
vascularity  in  the  inflamed  part  by  depressing  the  circulation,  and 
for  this  end  we  possess  two  well-known  agents,  aconite  and  tar- 
tarated  antimony.     2.  To  soothe  and  calm  the  excited  or  inflamed 


ON   DISEASES   OF   THE   BRAIN.  567 

encGjDlialic  centres,  and  this  is  best  attained  by  the  use  of  iodide  of 
potassium.  These  agents  then  maj'  be  combined.  Chloral  hydrate 
probably  produces  both  of  these  aft'ects.  It  must,  however,  be 
borne  in  mind  that  all  depressants  in  children  are  apt  to  produce 
varying  results,  even  ordinary  doses  v^uU  induce  at  times  an  un- 
anticipated degree  of  prostration,  out  of  all  proportion  to  the  dose 
employed.  Careful  observation  and  repeated  attention,  at  com- 
paratively short  intervals,  are  therefore  demanded,  in  order  to 
note  if  the  remedies  are  exercising  too  great  an  effect. 

Each  case  having  special  and  peculiar  features,  no  plan  can  be 
laid  down  as  suitable  for  all.  In  the  acute  and  early  stages  of  the 
disease,  mercury  is  a  remedy  of  undoubted  value,  and  ought  to  be 
employed,  but  only  as  a  purgative  to  thoroughly  empty  the  bowels, 
and  to  insure  a  free  discharge  of  bile.  The  bodily  powers  must 
be  carefully  estimated  before  we  resort  to  it.  It  is  essential  that 
the  bowels  be  kept  freely  open,  and  the  renal  secretion  encour- 
aged, as  tending  to  lessen  cerebral  congestion.  The  employment 
of  calomel  on  the  plea  of  preventing  exudation  is  an  exploded 
theory.  After  this,  iodide  of  potassium  is  the  remedy  to  rely  on 
in  meningitis. 

The  head  is  to  be  shaved,  and  cold  affusion  applied,  either  by 
ice  in  a  bladder,  with  the  eftect  vigorously  watched,  whilst  the 
delirium  is  fierce  and  active,  or  what  is  preferable,  the  ice-cap,  as 
employed  at  the  Samaritan  Hospital  in  cases  of  surgical  fever  and 
cerebral  congestion.  At  the  same  time  mustard  poultices  may  be 
applied  to  the  calves  of  the  legs. 

Leeches  have  been  used,  but  they  are  not  very  satisfactory,  and 
can  scarcely  be  advocated  in  3-oung  children,  the  loss  of  blood  not 
being  well  borne,  except  in  very  special  cases.  The  pallor  of  the 
face,  and  frequency  of  pulse  that  follow  their  use,  should  make 
us  extremely  timid  of  their  application  ;  and  yet,  from  the  cere- 
bral congestion  witnessed  in  some  fatal  cases,  the  abstraction  of 
blood  appears  warrantable.  "When  used  they  should  be  applied  to 
the  vertex,  or  close  behind  the  ears,  where  pressure  can  be  readily 
applied,  if  the  bleeding  is  too  active,  and  there  is  fear  of  the  child 
losing  too  much  blood.  They  may  be  employed  with  greater 
chance  of  good  than  in  the  tubercular  form  of  the  disease,  where 
the  evil  might  be  aggravated.  Dr.  Wilks  is  in  favor  of  leeching. 
He  says,  "  I  believe,  therefore,  that  at  the  present  day,  if  you 
think  a  child  has  acute  meningitis  setting  in,  you  will  have  no 


588  DISEASES    OF    CHILDEEX. 

better  treatment  at  hand  than  the  application  of  leeches,  and  the 
saline  with  antimony.'"^ 

Salines,  as  chlorate  and  citrate  of  potash,  are  to  be  recommended 
when  the  more  acute  symptoms  are  lessening,  or  the  urine  is  turbid 
and  his^h-colored.  Hydrate  of  chloral  is  sometimes  useful,  and 
especially  bromide  of  potassium  in  large  doses  when  a  sedative  is 
indicated.  The  latter  remedy  will  often  check  the  tendency  to 
convulsions  (Ringer).  Small  quantities  of  milk,  and  beef  tea  later 
on,  are  fitting  forms  of  nourishment.  In  the  early  stages  the 
diet  should  be  low  and  unstimulating.  Cold  drinks  may  be  given 
freely.  For  the  debility  and  emaciation  that  result,  an  ordinary 
tonic  treatment,  including  ammonia,  quinine,  iron,  and  strychnia 
are  to  be  employed. 

When  coma  has  set  in,  a  blister  at  the  na.pe  of  the  neck,  or 
behind  the  ears  is  advisable,  and  stimulants,  as  ammonia,  spirit  of 
chloroform,  etc.,  should  be  given  in  the  place  of  mercurials  and 
purgatives. 

Acute  meningitis  runs  a  rapid  course  in  spite  of  bleeding, 
leeching,  and  the  most  active  treatment.  It  may  destroy  life  in 
twenty-four  hours^  and  the  patient  never  recover  consciousness 
from  the  time  of  the  attack,  or  it  may  last  some  weeks  in  excep- 
tional cases. 

Tubercular  Meningitis. — The  pia  mater  is  the  membrane  in  which 
the  deposition  of  tubercle  takes  place  in  the  form  of  miliary 
granules.  According  to  some  pathologists  they  are  not  seen  on 
the  free  surface  of  the  arachnoid,  or  in  any  way  connected  with 
it ;  but  this  to  me  is  a  doubtful  point,  seeing  the  affinity  which 
tubercle  has  for  serous  membranes  in  other  parts  of  the  body. 
Unlike  its  loose  investment  around  the  spinal  cord,  the  arachnoid 
is  closely  adherent  to  the  pia  mater,  except  where  the  latter  mem- 
brane dips  into  the  convolutions,  and  the  arachnoid  stretches 
across  them.  Here  the  tubercles  in  cases  of  meningitis  are  most 
abundantly  seen,  and  they  are  often  found  in  this  situation  when 
they  cannot  be  detected  in  anj-  other.  This  looks  as  though  the 
arachnoid  had  some  attraction  for  the  deposit,  as  the  pia  mater 
quits  its  fellow-membrane  at  the  base  of  the  brain,  where  its  un- 
even surface  admits  of  the  divergence  being  readily  traced.  The 
connective  tissue  of  the  arachnoid  resembles  the  delicate  structure 
of  the  pia  mater  itself,  which  is  made  up  of  flat  membranous  cells, 

*  On  Diseases  of  the  Nervous  System,  1878,  p.  157. 


ON    DISEASES    OF   THE    BEAIN".  569 

connective-tissue  bundles,  and  elastic  fibres,*  so  that  where  the 
two  membranes  are  firmly  united,  it  is  not  possible  to  say  which 
was  the  most  attractive  to  the  morbid  change.  The  arachnoid, 
then,  having  all  the  characters  of  a  serous  membrane,  and  pre- 
senting tubercular  deposit  at  its  freest  part,  seems  to  be  as  much 
a  factor  in  the  process  as  the  pia  mater.  It  is  important  to  exer- 
cise great  care  in  looking  for  these  small  granules  lest  they  escape 
notice ;  they  should  be  diligently  sought  for  wherever  any  exuda- 
tion of  yellow  fibrinous  or  amorphous  matter  is  found.  These 
miliary  granulations  may  be  observed  in  the  Sylvian  fossa,  and 
the  longitudinal  fissure,  and  in  the  course  of  the  vessels  along  the 
base  of  the  brain  to  the  medulla  oblongata,  especially  about  the 
cerebellum,  where  the  eighth  and  ninth  pair  of  nerves  may  be  con- 
cealed by  a  semi-gelatinous  eflL'usion.  I  have  seen  the  origin  of 
the  olfactor}^  nerves,  the  tuber  cinereura,  locus  perforatus,  the  com- 
missure of  the  optic  nerves,  and  the  anterior  half  of  the  pons 
varolii  completely  hidden  by  this  exudation.  The  growths  are 
the  size  of  pins'  heads,  of  a  grayish-yellow,  semi-transparent  color, 
and  have  long  since  been  ascertained  not  to  depend  on  any  inflam- 
matory products,  as  was  formerlj^  supposed.  Sometimes  they  may 
be  observed  adherent  to  the  pia  mater,  where  it  dips  down  between 
the  convolutions ;  but  at  the  base  of  the  brain,  where  the  arach- 
noid covers  the  cerebellum,  they  may  be  detected  clustering  to- 
gether in  the  greatest  numbers — not,  however,  that,  as  far  as  we 
know,  the  number  of  these  tubercular  granulations  bears  anv  cor- 
responding  relation  to  the  extent  of  inflammation,  or  the  rapidity 
with  which  the  symptoms  are  developed.  These  tubercular  growths 
appear  to  be  in  intimate  relation  with  the  smallest  arteries,  on  the 
sides  of  which  they  form  a  distinct  projection.  They  consist 
chiefly  of  small  cells,  a  little  larger  than  a  blood-corpuscle,  and 
numerous  free  nuclei. f  The  inflammation  associated  with  these 
small  bodies  has  no  distinctive  character  from  ordinary  inflamma- 
tory changes.  Sometimes  caseous  and  degenerative  products  are 
set  up,  as  maybe  observed  in  scrofulous  inflammation;  or  they 
undergo  similar  changes  themselves,  and  lead  to  eftusion  of  serum 
or  seropurulent  matter  in  the  ventricles,  which  is  one  of  thecom- 


*  Frey's  Histology,  by  Barker,  1874,  p.  599. 

f  For  an  interesting  account  of  tlie  minute  anatomy  of  meningeal  tubercle,  I  refer 
the  reader  to  Jones  and  Sieveking's  Pathological  Anatomy,  by  Dr.  Payne,  1875, 
pt  212. 


570  DISEASES    OF    CHILDREX. 

monest  consequences  of  acute  hydrocephalus.  The  choroid  plexus 
is  full  and  vascular  in  a  few  cases,  and  the  walls  of  the  ventricles 
present  a  faint  pink  hue.  The  plexus  may  be  pale,  however,  and 
the  surface  of  the  corpus  callosum  and  optic  thalami  soft  and  ero- 
ded. Tubercular  meningitis  is  not  invariably  associated  with  the 
deposit  of  tubercle  in  other  parts  of  the  body.  Though  we  should 
carefully  look  for  tubercular  deposit,  or  some  signs  of  strumous 
inflammation  in  the  lungs  and  bronchial  glands,  yet  such  are  not 
always  found  in  the  most  marked  cases  of  tubercle  in  the  menin- 
ges;  and  it  is  strange  that  the  connection,  close  as  it  certainly  is, 
should  be  set  down  by  many  authors  as  of  almost  invariable  occur- 
rence. 

"The  distinctive  characters  of  tubercular  meningitis  are  the 
absence  of  lymph  on  the  surface  of  the  brain  (in  this  it  differs 
from  simple  meningitis),  a  flattening  of  the  hemispheres,  lymph 
at  the  base,  tubercles  in  the  pia  mater  following  the  course  of  the 
vessels,  and  increased  fluid  in  the  ventricles,  with  softening  of 
their  walls.  Even  if  tubercles  were  not  visible  to  the  naked  eye, 
the  rest  of  these  characters  would  at  once  indicate  the  nature  of 
the  disease,  and  the  microscope  will  always  find  the  tubercles 
along  the  vessels."* 

Symptoms. — This  disease  is  usuall}^  met  with  in  children  of  from 
one  to  seven  or  eight  years  of  age.  Of  48  males  afi'ected  at  the 
Children's  Hospital  between  August,  1862,  and  March,  1871,  35 
•were  under  five  years  of  age ;  and  of  33  females,  23  were  under 
five  years  of  age.f  It  may  happen  to  children  of  a  few  months 
old  ;  but  the  ages  I  have  given  are  the  most  frequent.  AVhen 
children  grow  older  the  lungs  are  more  likely  to  be  attacked  than 
the  brain.  As  in  some  other  forms  of  nerve  disorder,  the  child 
usually  exhibits  evidence  of  impaired  health  for  some  time  before 
the  outbreak  of  cerebral  symptoms:  "  The  disease  is  less  acute 
than  that  last  mentioned  (acute  meningitis)  generally  running  a 
course  of  three  or  four  weeks,  with  symptoms  less  violent. "|  But 
the  sjmiptoms  may  arise  suddenly,  and  run  a  fatal  course  in  a  few 
days.  There  is  an  absence  of  animation  and  habitual  liveliness 
about  the  child.     It  throws  its  amusements  abruptly  on  one  side, 

*  Wilks  and  Moxon's  Pathological  Anatomy,  1875,  p.  212. 

t  Reynolds's  System  of  Medicine,  article  Tubercular  Meningitis,  by  Dr.  Gee,  1872, 
vol.  ii,  p.  384. 

X  Wilks  and  Moxon's  Pathological  Anatomy,  1875,  p.  210. 


ON    DISEASES   OF    THE    BRAIN.  571 

as  if  they  tired  or  annoyed  it,  and  it  falls  asleep  in  the  daytime. 
It  cries  without  reason,  and  quarrels  Avith  its  companions.  It  is 
morose,  shy,  and  timid  ;  and  becomes  inconsolable  if  its  mother 
leaves  it  or  intrusts  it  to  the  care  of  a  stranger.  It  may  have 
been  losing  flesh,  and  looking  delicate  and  pallid  ;  but  not  more 
than  is  constantly  observed  in  young  children  who  are  otherwise 
in  average  health.  In  this  premonitory  stage  there  may  be  simple 
irritation  or  congestion  of  the  brain,  and  until  some  inflammation 
occurs,  the  child  may  go  on  in  this  condition  for  an  indefinite 
period.  If  these  threatening  symptoms  attract  attention  they  may 
sometimes  be  subdued  by  appropriate  treatment,  and  v/eeks  of 
careful  watching  and  strict  diet  may  postpone  the  coming  evil ; 
for  it  is  doubtful  whether  true  meningitis  ever  develops  itself  sud- 
denly, some  obscure  symptoms  of  a  local  or  general  nature  may 
have  escaped  observation.  The  symptoms  that  demand  espe'cial 
notice  are  vomiting,  constipation,  alteration  of  the  pulse  and  res- 
piration, strabismus,  and  local  or  general  convulsions  and  paralysis. 
In  a  diagnostic  point  of  view  there  are  several  considerations  to 
be  analyzed  and  dwelt  upon.* 

Vomiting  is  a  frequent  symptom,  and  often  steals  on  insidiously. 
The  child  takes  its  food  as  usual,  but  rejects  it  the  instant  it  is 
swallowed,  yet  it  is  willing  to  eat  again  inmiediately  afterwards. 
It  may  be  sick  only  once  in  the  day,  or  oftener  ;  but  as  the  disease 
advances  sickness  becomes  more  frequent,  and  the  stomach  will 
reject  plain  water.  This  form  of  vomiting  is  unaccompanied  by 
pain  or  gastric  disturbance.  Where  this  symptom  has  been  of 
some  duration  the  eyes  are  sunken  and  have  a  languid  look,  wdiilst 
the  face  is  pinched  and  thin.  It  may  be  present  in  the  subacute 
as  well  as  in  the  acute  varieties  of  meningitis,  and  maj- ,  in  the 
former  cases,  have  lasted  some  considerable  time  without  attract- 
ing notice.  In  the  absence  of  headache  it  is  often  overlooked,  but 
having  once  set  in  it  usually  goes  on,  the  appetite  diminishing 
meanwhile  ;  the  belly  is  flattened  and  concave,  the  edges  of  the 
receding  ribs  have  a  sharp  outline,  and  the  intercostal  spaces  are 
sunken  and  retracted.  Vomiting,  however,  is  not  invariably 
present,  and  a  case  of  tubercular  meningitis  may  run  its  course 
from  beginning  to  end  without  this  symptom. 

Constipation^  as  in  simple  encephalitis,  is  the  rule,  and  a  full  dose 

*  The  diagnosis  from  pneumonia,  pleurisy,  and  typhoid  fever,  is  given  in  the  chap- 
ters on  these  subjects. 


572  DISEASES    OF    CHILDREX. 

of  aperient  medicine  is  required  to  move  the  bowels.  The  char- 
acter of  the  motions  is  subject  to  much  change.  They  are  gener- 
ally dark,  or  clay-colored,  and  fetid  ;  but  they  may  be  healthy- 
looking  and  only  diminished  in  quantity.  Still  there  may  be  diar- 
rhoea, and  this  circumstance  should  not  beguile  us  into  lookins: 
elsewhere  for  an  explanation  of  the  head  symptoms.  Diarrhcea 
and  fever  in  meningitis  are  confessedly  embarrassing  signs,  as  they 
are  the  two  characteristic  and  concomitant  sjnnptoms  of  tj'phoid 
fever.  As  the  disease  advances  the  motions  may  be  passed  un- 
consciously. 

There  is  not  mucli  thirst  in  the  absence  of  febrile  phenomena, 
except  in  those  cases  of  tuberculosis  in  other  organs  in  the  body, 
when  the  evening  temperature  runs  up  to  105°  or  107°,  and  the 
skin  is  hot  and  pungent ;  in  the  latter  stages  of  uncomplicated 
meningitis  the  febrile  phenomena  are  high.  As  the  disease  ad- 
vances and  sensibility  is  blunted,  the  bladder  is  apt  to  become 
paralyzed,  and  the  urine  aramoniacal  and  albuminous.  I  have  seen 
the  bladder  distended  up  to  the  umbilicus,  and  requiring  the  use 
of  the  catheter.  Vogel*  says  he  has  not  found  albumen  in  the 
urine  of  these  patients;  but  if  it  is  searched  for  carefullj-,  we  shall 
detect  it  frequently  in  this,  as  well  as  in  many  of  the  congestive 
and  inflammatory  diseases  of  children.  When  it  is  small  in  amount, 
and  the  solids  of  the  urine  are  sufliciently  eliminated,  it  is  of  no 
great  import,  and  does  not  add  to  the  gravity  of  the  case. 

The  imlse  deserves  our  closest  attention  in  this  disease.  It  is 
variable  in  force  and  frequency  ;  and  this  fluctuation  may  be  taken 
to  indicate  pressure,  either  from  fluid  slowly  poured  out  into  the 
ventricles,  or  from  increasing  congestion  of  the  cerebral  vessels. 
In  the  early  stage  of  the  disease  the  pulse  may  be  quicl^eued,  but 
it  is  usually  regular  ;  later  on  it  lessens  in  frequency,  and  we  have 
the  slow  pulse  of  hydrocephalic  disease.  It  may  be  slow  one  hour 
and  quick  another,  and  become  rapid  or  irregular  after  food,  and 
whilst  digestion  is  proceeding.  If  that  stage  of  the  disease  is 
reached  when  it  is  fluttering  and  too  rapid  to  be  counted,  it  is 
significant  of  great  danger,  and  the  end  is  not  far  distant.  We 
cannot  infer  with  anything  like  accuracy  that  the  state  of  the 
pulse  or  pupils  is  indicative  of  eftusion  or  congestion,  nor  can  we 
make  out  with  certainty  what  changes  have  occurred  in  the  con- 
sistence of  the  brain. 

■■■'  Diseases  of  Children,  p.  364,  1875. 


ON    DISEASES    OF    THE    BRAIN.  573 

The  character  of  the  resjnratioji  is  a  most  significant  sign.  It  is 
similar  to  what  is  observed  in  simple  meningitis,  irregular  or  flut- 
tering— hydrocephalic  sighs — tranquil,  as  if  momentarily  arrested, 
then  gasping  as  if  death  were  at  hand.  This  is  an  indication  of 
nervous  exhaustion  and  unsteadiness  in  the  respiratory  centre. 
When  the  pulse  is  quick  the  respiration  is  also  accelerated  in  many 
cases ;  but  these  functions  do  not  hold  the  close  and  orderly  rela- 
tionship which  is  generally  assigned  to  them.  The  temperature 
may  "run  up  to  10-1°  in  cases  of  surgical  pyrexia  without  any 
increase  of  respiration — it  may  be  101°  and  the  respiration  42 — 
and  when  the  temperature  reaches  103°  it  may  fall  to  20.  So 
with  the  impulse,  when  it  has  fallen  as  low  as  68  strokes  in  a 
minute,  the  temperature  has  been  known  to  reach  104°.  Some 
allowance  must  be  made  for  the  diflerence  in  this"  class  of  cases, 
since  in  tubercular  meningitis,  with  increasing  venous  congestion, 
the  respiratory  movements  are  excited  to  greater  frequency. 

Headache  is  a  frequent  symptom  at  one  or  another  stage  of  the 
disease.  I  have  met  with  it  at  the  period  of  invasion,  and  noticed 
in  one  well-marked  case  how  the  little  boy  carried  his  hand  to  his 
head  when  he  was  too  young  to  speak.  When  the  pain  is  parox- 
ysmal, or  one  day  present  and  another  absent,  it  may  be  mistaken 
for  neuralgia ;  and  in  the  absence  of  fever  I  have  had  my  doubts 
of  its  exact  nature.  When  it  is  continuous  or  severe,  the  child 
will  cry  out  -with  it,  and  if  old  enough  will  tell  you  that  his  head 
aches. 

In  genuine  meningeal  inflammation  the  muscles  of  the  neck  are 
contracted  and  the  head  is  thrown  back.  In  states  of  simple  irri- 
tation and  passive  effusion,  the  muscles  are  relaxed  and  the  child 
cannot  support  his  head.  When  laid  down  to  sleep  he  will  rotate 
it  from  side  to  side  and  utter  piercing  cries  of  pain.  He  has  start- 
ings  and  tremors  in  his  restless  sleep,  and  the  pupils  turn  upwards 
under  the  half-closed  eyelids  and  reveal  the  conjunctiva.  Squint- 
ing may  be  observed  in  the  earl}^  periods  of  the  disease  when  it  is 
acute,  and  also,  in  many  slow  and  chronic  cases,  long  before  the 
brain  is  suspected  of  going  wrong;  but,  as  a  rule,  it  is  a  late 
symptom  of  the  disorder,  and  is  complicated  with  inequality  of 
the  pupils,  and  the  absence  of  sensibility  in  the  conjunctiva,  when 
the  finger  is  passed  across  the  eyeball  in  sleep. 

Hemiplegia  and  paralysis  of  one  arm  and  leg  are  to  be  noticed 
as  occurring  in  the  latter  stages. 


574  DISEASES   OF   CHILDEEN. 

The  two  following  cases  of  tubercular  meningitis  exeraplifj 
some  of  the  leading  features  of  the  complaint  to  which  I  have 
referred. 

Case  I. — G.  C ,  ?et.  4,  was  one  of  two  children.     The  child 

had  sharp  features,  dark  hair,  and  prominent  forehead.  Father 
and  mother  health}^ ;  no  others  in  famil3\  When  brought  to  Dr. 
Wynn  Williams  as  an  out-patient,  May  16th,  1877,  it  was  stated 
that  the  child  avus  perfectly  well  till  a  fortnight  before,  and  since 
then  she  was  faint  and  could  not  eat ;  she  was  generally  hot,  and 
the  tongue  furred.  A  mercurial  purge  and  a  saline  mixture  were 
ordered.  On  June  2d  there  were  signs  of  low  fever,  and  quinine 
"was  ordered  three  times  a  day.  On  the  9th  there  w^as  some 
diarrhoea. 

On  the  11th,  when  admitted  into  the  Dorset  Street  Hospital, 
the  temperature  at  1  p.m.  was  100.2°  ;  at  5  p.m.  101°  ;  pulse  88  ; 
respiration  quiet.  The  child  appeared  very  languid,  the  tongue 
was  furred,  the  skin  hot,  and  the  bowels  costive.  A  mixture  of 
citrate  of  potash  and  sulphate  of  magnesia  was  ordered. 

On  the  12th  at  8  a.m.  the  temperature  w^as  100°,  and  the 
bowels  had  acted  twice.  At  5  p.m.  she  could  protrude  her  tongue, 
and  was  sensible  ;  temperature  102.2°,  pulse  126.  8  p.m.  she  had 
a  convulsion,  and  w-as  not  sensible  afterwards ;  temperature 
102.2°.  12  P.M.,  temperature  103.6°,  breathing  heavily  and 
quickly. 

13th.— 1.30  A.M.  died. 

Post-mortem  Examination  {eighteen  hours  after  death)  by  Mr.  A. 
Doran. — Body  generally  pale,  except  some  marks  of  hypostatic 
congestion  on  the  back  and  posterior  part  of  shoulders.  The  cal- 
varium  was  adherent  to  the  dura  mater.  In  the  anterior  portion 
of  the  right  hemisphere,  at  the  part  corresponding  to  the  posterior 
aspect  of  the  frontal  bone,  two  or  three  of  the  convolutions  at  this 
part  were  separated,  and  a  cavity  filled  with  serous  fluid  was  seen 
large  enough  to  contain  a  walnut.  There  was  no  pus  or  lymph  in 
the  cavity,  but  at  its  base  a  few  enlarged  vessels  ramifying  in  the 
pia  mater.  The  cavity  immediately  became  apparent  when  the 
arachnoid  covering  it  \vas  opened,  and  this  portion  of  the  mem- 
brane, unlike  the  rest,  was  of  a  tawny  yellowish  color,  resembling 
a  weak  solution  of  iodine  or  w^ash  leather.  At  the  central  line  of 
the  longitudinal  fissure,  at  the  upper  part  of  the  cerebrum,  w^as  a 
patch  of  yellow,  purulent-looking  lymph,  the  size  of  a  fourpenny 


ON   DISEASES   OP   THE   BRAIN.  575 

piece,  tmd  a  smaller  patch  near  it.  The  brain  was  generally 
much  congested,  especially  posteriorly ;  at  the  base  around  the 
optic  commissure  was  a  layer  of  lymph  and  shreddy  tissue,  with 
small  dots,  common  enough  in  tubercular  meningitis.  There  was 
a  large  amount  of  subarachnoid  fluid  of  a  pale,  serous,  milky 
color.  There  were  about  two  ounces  and  a  half  of  serous  iluid  in 
the  lateral  ventricles. 

The  mesentci-}/ was  studded  with  enlarged  glands,  the  average 
size  being  that  of  a  small  nut.  The  live)-  was  generally  pallid  and 
studded  with  tubercles,  it  extended  into  the  left  hypochondrium, 
touching  the  ribs  on  either  side,  and  there  was  not  a  quarter  of  an 
inch  of  healthy  liver  free  from  these  granulations  ;  the  peritoneum 
generally  was  studded  with  them,  but  especially  that  which  covered 
the  diaphragm,  where  they  were  seen  in  large  patches,  the  size  of 
the  palm  of  the  hand  at  the  centre,  and  honeycombed.  The  spleen 
was  thickly  covered  with  them  ;  intestines  distended  with  gas  ;  no 
peritoneal  efl'usion.  Both  lungs  were  also  irregularly  studded 
with  tubercles,  but  not  more  at  the  apex  than  the  centre  or  base. 
The  central  lobes  were  most  congested. 

Case  II.— A.  F.,  set.  2 J  years,  was  admitted  into  the  Samaritan 
Hospital  under  Dr.  Wynn  Williams,  May  24th,  1877,  suffering 
from  synovitis  of  the  right  knee-joint,  of  seven  months'  standing. 
The  child  had  been  brought  up  by  hand,  and  much  neglected  ;  she 
was  thin  and  delicate,  had  fair  hair,  and  refined  features.  A  splint 
was  applied  to  the  joint  in  order  to  keep  it  at  rest ;  the  tempera- 
ture was  normal,  and  there  was  nothing  apparently  wrong  about 
her  besides.  On  the  27th,  happening  to  be  in  the  ward,  I  observed 
that  she  was  partially  asleep  and  restless,  crying  out  at  intervals 
in  sharp,  piercing  tones.  The  pulse  was  quiet  and  the  tempera- 
ture normal.  I  made  the  observation  that  I  feared  head  symptoms 
were  threatening.  On  the  29th  the  temperature  was  still  98.8° 
and  the  pulse  100,  but  the  child  was  constantly  sleeping  and  ap- 
parently indifi:erent  to  all  that  went  on  around  it.  On  the  30th 
ordered  calomel  gr.  iss.,  jalapin  gr,  i.  At  six  in  the  evening  I  saw 
the  child,  with  Dr.  Williams,  and  made  a  note  to  the  following 
effect :  "  Temperature  100°  ;  pulse  120,  small  and  thrilling  ;  respi- 
ration 24,  irregular  and  sighing ;  the  pupils  are  of  medium  size, 
but  eyes  half  open  and  unconscious  since  yesterday  morning. 
Tongue  covered  with  a  creamy  fur ;  belly  concave ;  respiration 


576  DISEASES  or  children. 

abdominal  (probably  eftusion  into  ventricles) ;  bowels  freely  moved 
from  powder." 

June  1st. — Temperature  at  8  a.m.  99°  ;  at  2  p.m.  99.6°,  was 
mucli  convulsed  ;  at  8  p.m.  99.2°.  During  the  night,  alternate 
flushing  and  pallor  of  the  cheeks — eyes  half  open,  but  resists  when 
ej^eball  is  touched,  and  remains  sleeping  in  a  semi-comatose  state 
— moving  hands  about  and  eyes  squinting;  lower  eyelids  shrunken, 
head  hot,  pulse  170,  verj- small  ;  respiration  quiet;  bowels  again 
open  twice. 

2d.— Temperature  at  8  a.m.  98.8°  ;  at  8  p.m.  98°.  During  the 
night  the  child  was  much  convulsed  in  the  limbs,  and  was  never  at 
any  moment  conscious ;  veins  of  forehead  and  scalp  much  dis- 
tended;  pulse  160;  respiration  20,  a  quarter  of  a  minute  some- 
times elapsing  before  a  respiration  was  taken ;  lips  and  teeth  dry 
from  the  mouth  being  half  open.  The  tongue  was  covered  with 
a  thick  whitish  fur ;  eyes  staring  ;  thumbs  fixed  in  palms  of  hands ; 
can  swallow  a  little  milk  when  put  into  her  mouth.  4.30  p.m. 
pulse  136,  weaker  ;  constant  twitching  of  right  eye  and  arm.  The 
motions  and  urine  passed  unconsciously  for  two  days. 

3d.— Temperature  at  8  a.m.  99.4°,  at  1  p.m.  100.6°  ;  pulse  164  ; 
respiration  20.  The  child  now  lay  in  an  unconscious  state,  and 
the  right  cheek  was  much  flushed ;  the  respiration  w^as  irregular, 
but  extremely  quiet,  a  quarter  of  a  minute  sometimes  elapsed 
before  an  inspiration  was  taken.  A\'hen  turned  on  her  side  and 
the  thermometer  was  introduced  into  the  rectum  she  ofiJered  no 
resistance,  and  appeared  not  to  feel  it.  She  was  quite  insensible, 
with  her  eyes  half  open,  though  when  the  eyeball  w^as  touched 
she  appeared  to  feel  it,  and  moved  her  head  a  little ;  motions  and 
urine  still  passed  under  her.  Made  an  eftbrt  to  swallow  when  a 
little  milk  was  put  into  her  mouth.  Temperature  at  5  p.m  101° ; 
at  8  p.m.  101.6°. 

The  breathing  now  became  heavy  and  stertorous,  with  mucus 
rattling  in  the  throat,  and  the  cheeks  were  livid  ;  the  lips  were 
also  dusky  and  the  nostrils  quiet.  The  pulse  was  too  rapid  to  be 
counted ;  the  temperature  was  taken  in  the  axilla  immediately 
before  death  at  10.30,  when  it  reached  105.6°. 

Post-mortem  Examination  (twcnti/  liours  after  death)  by  Mr.  Allan 
Doran. — Tibia  slightly  displaced  backwards  ;  no  excessive  synovial 
fluid  was  found,  nor  any  adhesion  but  synovial  fringes  were  vas- 


ON    DISEASES   OF    THE    BRAIN.  577 

ciilar  and  liypertroiDhied,  invading  the  margins  of  the  condj'les  of 
the  femur,  which  were  softened. 

On  removing  the  scalp  the  ealvarinm  had  a  dark  venous  appear- 
ance; there  was  perfect  union  of  the  fontanelles.  The  dura  mater 
was  everywhere  distended  and  adherent  along  the  line  of  the  lon- 
gitudinal sinus;  there  was  great  congestion  of  all  the  veins  of 
every  magnitude,  including  venous  capillaries.  The  meningeal 
artery  and  veins  accompanying  it  were  distended.  The  convolu- 
tions were  flattened,  and  milky  patches  of  whiteness  were  seen 
over  the  arachnoid;  texture  of  brain  very  soft.  In  the  subarach- 
.noid  spaces  there  were  about  four  ounces  of  fluid  (clear  and  serous) 
from  the  locus  perforatus  to  the  medulla  oblongata,  the  arachnoid 
was  infiltrated  with  small  specks  of  tubercle.  On  cutting  into  the 
hemispheres  the  gray  matter  was  slightly  congested,  the  puncta 
of  the  white  matter  exuded  freely.  About  half  an  ounce  of  serous 
fluid  in  both  lateral  ventricles.  The  sensorial  ganglia,  the  pons, 
the  crura,  and  medulla  oblongata  were  all  firm  and  free  from  con- 
gestion. 

The  right  lung  was  moderately  congested,  with  miliary  tubercle 
dissenjinated  throughout,  less  at  apex,  where  the  congestion  was 
slight,  than  at  the  base,  where  the  lung  was  very  dark  ;  the  left 
lung  w^as  still  further  congested  from  the  presence  of  tubercles. 
Right  cavity  of  heart  distended.  Liver  and  kidneys  healthy. 
Mesenteric  glands  all  enlarged,  the  largest  the  size  of  a  French 
bean,  with  caseous  tubercle  in  the  larger  ones. 

Microscopical  examination  of  the  lungs:  Adenoid  cells  very 
freely  deposited  in  stroma;  no  proliferation  of  epithelial  lining  of 
pulmonary  vesicles,  characteristic  of  acute  tuberculosis  ;  death  be- 
fore secondary  catarrhal  pneumonia.  Adenoid  cells  so  abundant 
as  to  cause  collapse  and  occlusion  of  vesicles. 

Chronic  Basilar  31eningitis. — There  is  a  variety  of  acute  and 
chronic  meningitis  attacking  the  base  of  the  brain  [basilar  menin- 
gitis) very  well  described  by  Dr.  Cross,  of  I^ew  York.*  In  the 
adult  it  is  not  a  common  affection ;  in  forty-seven  cases  of  this  local- 
ized aiiection  forty-three  were  acute,  four  only  chronic,  as  proved 
by  post-mortem  examination.  Gintrac  says,  "This  species  is  dis- 
tinguished by  its  seat  at  the  inferior  surface  of  the  brain,  by  its 
circumscribed  extent,  and  especially  by  the  relation  of  the  affected 

*  On  Chronic  Localized  Basilar  Meningitis,  Psychological  and  Medico-Legal 
Journal,  April,  1875,  p.  220. 

37 


578  DISEASES    OF    CHILDEEN. 

part  with  the  central  region  and  with  the  cerehral  ventricles."* 
The  symptoms  depend  on  the  intensity  of  inflammation,  as  well  as 
on  its  seat  and  extent.  When  a  small  portion  of  the  memhranes 
at  the  base  of  the  brain  are  involved,  the  symptoms  are  not  so  severe 
as  when  a  larger  extent  of  brain  is  implicated.  Thus,  the  optic 
nerve  of  one  side  may  be  atrophied,  whilst  the  other  is  normal, 
and  the  inflammatorj^  exudation  or  softening  may  extend  to  the 
third,  fourth,  fifth,  sixth,  seventh,  or  eighth  pair  of  nerves,  and  so 
set  up  a  different  set  of  sj^mptoms — symptoms  of  a  local  character, 
shifting  from  one  side  to  the  other.  The  third  nerve,  in  the 
majority  of  cases  of  basilar  meningitis,  is  paralyzed. 

In  thirteen  cases  recorded,  the  third  nerve  was  partially  para- 
lyzed in  nine,  and  in  most  cases  on  the  left  side  ;  in  nine  cases 
there  was  strabismus,  and  in  five  of  these  it  was  external  and  on 
the  left  side;  the  pupils  Avere  dilated  in  eight  cases,  and  contracted 
in  one ;  there  was  obscureness  of  vision  in  four ;  ptosis  in  five ; 
blindness  in  one  case  ;  in  another  loss  of  sight  in  both  e^-es. 
Headache  was  a  prominent  symptom,  not  confined  to  any  particular 
locality;  in  twelve  cases  generally  severe,  dull,  and  .throbbing,  and 
ushered  in  gradually  ;  once  it  was  developed  suddenly.  Vertigo 
was  present  in  seven  cases,  paralj'sis  in  eight  cases.  In  acute 
cases,  paralysis  is  the  exception,  exclusive  of  the  muscles  of  the 
eye.     In  the  chronic  form  it  is  most  frequently  marked. 

Chronic  basilar  meningitis  is  very  prone  to  change  its  position 
from  one  side  of  the  head  to  the  other.  The  symptoms  ma}'-  be 
well  defined  on  the  left  side,  as  ptosis,  strabismus,  dilatation  of  the 
pupil  of  the  left  eye,  and  headache  may  be  marked  on  the  left  side. 
These  may  disappear,  and  the  paralysis  be  cured,  and  after  the 
lapse  of  three  months  the  patient  may  have  the  same  symptoms 
on  the  other  side.  In  one  case  the  disease  was  ushered  in  by 
epileptiform  convulsions,  and  once  by  the  loss  of  consciousness. 
Anixsthesia  was  present  in  six  cases,  sometimes  confined  to  one 
side  of  the  face,  generally  to  one  arm  or  leg;  once  in  the  left 
limbs,  and  in  the  right  arm  ;  hyperfesthesia  in  no  instance.  The 
above  are  the  most  important  symptoms  of  chronic  basilar  menin- 
gitis;  but  the  following  symptoms  are  related  in  the  thirteen 
cases  alluded  to:  vomiting,  twice;  thirst,  thrice;  trismus,  thrice; 
fever,  once;  supination,  once;  opisthotonos,  twice ;  nausea,  once ; 
eyes  closed,  twice;  coma,  once;  dyspnoea,  once  ;  convulsive  move- 
ments, once ;  aphasia,  once.     The  chronic  form  is  most  common 

*  Maladies  de  I'Appareil  Nerveux,  vol.  ii,  Paris.     Quoted  from  Dr.  Cross. 


ox    DISEASES    OF   THE    BRAIN.  579 

between  the  ages  of  twenty-five  and  tliirt^'-five ;  the  acute  most 
frequent  between  one  and  ten  years  of  age. 

The  diagnosis  is  sometimes  attended  with  perplexity,  as  there 
is  no  one  pathognomonic  symptom  we  can  rely  on.  The  ophthalmo- 
scope is  a  great  aid  to  diagnosis;  and  if  the  eyes  are  in  a  normal 
state,  and  there  is  no  disease  of  the  orbit,  we  may  reasonably  con- 
clude that  the  disease  is  central.*  The  difficulties,  however,  are 
not  so  great  as  they  are  sometimes  made  to  appear,  for  in  nearly 
all  cases  I  have  seen  of  chronic  meningitis,  or  tubercular  menin- 
gitis, there  are  symptoms  present  that  point  to  the  base  of  the 
brain  as  involved  in  the  irritation,  and  I  have  never  seen  a  case 
after  death  where  the  post-mortem  has  not  revealed  exudative 
changes  in  the  latter  situation.  This  exudation  of  coagulable 
lymph  may  have  an  affinity  to  gather  round  the  great  nerves,  at 
the  base  of  the  brain.  Even  where  tumors  or  cysts  in  the  brain 
are  supposed  to  be  present,  or  softening  or  embolism  or  hsemorrhage 
to  have  happened,  the  duration  of  the  symptoms,  the  localized 
pain,  and  the  implication  of  nerves  would  assist  the  diagnosis. 

Treatment. — This  disease  is  so  uniformly  fatal  that  if  the  prac- 
titioner is  sure  that  the  meningitis  arises  from  tubercles  in  the 
membranes  he  cannot  hope  to  save  his  patient.  I  have  never 
known  a  case  recover.  AYe  have  already  seen  that  in  simple 
meningitis  death  usually  takes  place  in  a  few  days,  and  in  the 
graver  disease  under  consideration  we  have  not  only  cerebral  in- 

*  The  utility  of  the  ophthalmoscope  in  elucidating  the  intracranial  diseases  of 
children  is  shown  in  the  following  passage:  "L.  Heingel  (Jahrbuch  der  Kinderheil- 
kunde,  vol.  iii),  in  sixty-three  cases  of  intracranial  disease  in  children,  found  in  forty- 
seven  affections  of  the  optic  nerve  or  retina,  or  of  both.  There  were  eighteen  cases  of 
ncuroretinitis;  thirteen  of  neuroretinitis  with  congested  papilla;  four  of  congestion 
of  the  optic  nerve;  four  of  optic  neuritis  with  congested  papilla;  two  of  consecutive 
atrophy  of  the  optic  nerve;  six  of  atrophy  (genuine?)  of  the  optic  nerve;  and  in  six- 
teen the  ophthalraoscoijic  appearances  were  normal.  The  cases  are  thus  classified 
according  to  the  disease ;  in  thirty-one  cases  of  tubercular  meningitis  of  the  base  of 
the  brain  :  fifteen  of  neuroretinitis,  five  of  neuroretinitis  with  congested  papilla,  four 
of  congestion  of  the  optic  nerve,  two  of  incipient  atrophy,  one  of  atrophy,  and  four 
with  normal  fundus  of  the  eye.  In  ten  cases  of  the  same  disease  with  tuberculosis  of 
other  organs :  three  of  neuroretinitis,  one  of  optic  neuritis  with  congested  papilla, 
three  of  atrophy  of  the  optic  nerve,  and  four  normal.  In  fourteen  cases  of  cerebral 
tumor:  five  of  neuroretinitis,  two  of  neuroretinitis  with  subsequent  atro'phy,  four  of 
atrophy,  and  three  normal.  In  two  cases  of  oedema  cerebri — congestion  of  the  optic 
nerve.  In  the  remaining  seven  cases  (oedema  and  hyperjemia  of  the  meninges,  sclero- 
sis of  the  brain,  cerebro-spinal  meningitis,  and  effusion  in  the  cord),  tlie  fundus  of  tlie 
eye  was  normal.  It  was  observed  that  neuroretinitis  frequently  appeared  within  a  few 
days,  and  that  in  all  cases  it  affected  both  eyes  alike." — British  Medical  Journal,  Oc- 
tober 16th,  1875,  p.  492. 


580  DISEASES   OF   CHILDREN. 

flammation  to  contend  Avith,  but  an  inflammation  kept  np  by  tbe 
irritation  of  tubercular  deposit.  When  the  disease  is  threatening, 
every  attention  should  be  directed  to  remove  all  sources  of  irrita- 
tion that  lead  to  cerebral  congestion.  The  mental  powers  should 
not  be  taxed  by  lessons,  and  active  remedies  should  be  discontinued. 
The  head  should  be  kept  cool,  and  the  bowels  gently  stimulated 
by  the  mildest  laxatives ;  the  diet  should  be  nourishing  and  'Un- 
stimulating,  and  the  heat  of  the  sun  avoided.  Pure  air,  lively 
companions,  and  cheerful  surroundings  are  important ;  running 
and  active  phj^sical  exertion  should  be  discountenanced. 

The  occurrence  of  porrigo  and  obstinate  eruptions  of  the  face 
and  head  require  careful  management,  especially  during  dentition. 
In  the  autumn  of  1874  I  met  with  a  fair  and  delicate  child,  two 
years  of  age,  who  had  an  active  eczematous  eruption  of  the  whole 
scalp.  It  had  remained  obstinate  for  months,  sometimes  being 
dry  and  covered  with  crusts,  and  at  other  times  discharging  freely 
under  an  oil- skin  cap.  When  the  eruption  eventually  healed  the 
child  developed  strumous  symptoms,  and  the  health  began  slowly 
to  decline ;  the  face  shrank  in  size,  and  the  veins  in  the  head  were 
fuller;  sleep  at  night  was  restless  and  unrefreshing,  and  the  child 
refused  his  food.  After  several  convulsive  seizures  an  attack  of 
meningitis  supervened,  and  death  occurred  in  the  course  of  a 
week.     Xo  post-mortem  was  allowed. 

These  .cases  I  now  regard  with  caution,  and  prefer  the  continu- 
ance of  a  mild  skin  affection,  even  if  disfiguring,  to  the  dangers 
incident  on  suddenly  healing  it. 

Antiphlogistic  are  the  chief,  if  not  the  only,  remedies  by  which 
we  can  hope  to  afford  relief.  When  the  earliest  symptoms  are 
threatening,  as  heat  of  head,  peevishness,  and  irritability,  a  grain 
of  calomel  alone,  or  the  hyd.  c.  creta,  with  a  few  grains  of  rhu- 
barb, will  be  necessary  for  two  or  three  nights  in  succession,  or 
the  dose  may  only  be  required  twice  a  week.  A  mixture  of  sul- 
phate of  magnesia  is  useful  during  the  day,  with  a  small  quantity 
of  the  tincture  of  bark  or  nitrate  of  potash,  if  the  skin  is  hot  and 
the  urine  scanty.  The  infusion  of  calumba  and  syrup  of  rhubarb, 
in  equal  proportions,  is  a  good  stomachic  and  laxative.  If  there 
is  any  tendency  to  vomiting  or  headache,  calomel  at  the  outset  is 
the  best  remedy,  as  it  is  retained  on  the  stomach  when  other  drugs 
are  expelled;  not  that  its  good  effects  are  attributable  to  any  specific 
action,  but  it  thoroughly  unloads  the  liver  and  small  intestines, 
and  so  indirectly  relieves  cerebral  congestion.     With  regard  to  de- 


ON    DISEASES    OF    THE    BRAIN.  •     581 

pletorj  measures  we  have  to  remember  that  the  subjects  are  deli- 
cate and  of  strumous  constitution,  and  therefore  the  administra- 
tion of  mercury  and  purgatives,  important  as  they  may  be  at  the 
onset  of  the  disease,  will  need  great  care  and  judgment  as  the  dis- 
ease advances.  Whatever  is  done  in  this  way  must  be  done  early. 
The  same  remarks,  as  in  simple  meningitis,  are  applicable  to 
leeches  ;  they  require  to  be  employed  with  the  utmost  caution,  and 
are  only  of  use  in  the  early  stages  of  the  aflectiou,  even  if  they 
are  then  demanded.  If  employed  at  a  -later  stage,  when  the  mind 
is  getting  confused,  and  there  are  convulsive  movements,  the  loss 
of  blood  will  hasten  the  fatal  issue.  Cold  to  the  head,  when  there 
is  active  congestion  in  the  early  stages,  as  I  have  previously  recom- 
mended, is  a  remedy  of  great  value.  In  the  stage  of  effusion,  when 
there  is  restlessness  and  sleeplessness,  iodide  and  bromide  of  potas- 
sium will  be  found  valuable  because  of  their  power  in  diminishing 
excitability  aud  tranquillizing  the  nervous  system.  These  two 
remedies  given  together  may  control  secretion,  and  even  favor  ab- 
sorption if  it  has  occurred ;  bromide  of  potassium  administered 
alone  is  capable  of  lessening  reflex  action,  of  controlling  convulsive 
seizures,  and  of  reducing  to  some  extent  arterial  tension  and  vas- 
cular excitement,  when  the  more  depressing  action  of  chloral 
might  be  considered  hazardous.  Morphia  or  an  opiate  in  some 
form  may  be  required  when  there  is  excitement  and  wandering, 
and  the  little  patient  can  obtain  no  sleep.  But  great  caution  is 
necessary  in  administering  these  remedies  from  the  cerebral  ac- 
tivity to  which  they  give  rise  at  first,  and  the  danger  of  subse- 
quently depressing  the  circulation,  and  lessening  respiratory  action. 
Opium  acts  equally  upon  every  nerve-cell,  and  also  equally  upon  every 
nerve  fibre  ;  ....  it  not  only  lessens  cerebral  receptivity,  but  it 
alsOv  deadens  nerve  conductivity.*  A  sedative  will  sometimes  be 
borne  well  after  the  action  of  calomel  and  purgatives,  if  there  be 
scarcely  a.iiy  heat  of  the  head,  and  the  pulse  be  quick  and  feeble. 

Chronic  hychocephalus,  or  dropsy  of  the  brain,  consists  in  a  col- 
lection of  serous  fluid  within  the  head.  It  may  commence  in  utero 
and  seriously  impede  the  progress  of  labor,  when  it  is  termed  con- 
genital hydrocephalus,  or  the  head  may  not  begin  to  enlarge  till 
after  birth.  In  most  cases  the  fluid  is  efl:'used  into  the  ventricles 
(internal  hydrocephalus),  but  it  may  collect  between  the  dura 
mater  and  the  cranium,  or  between  the  dura  mater  and  the  arach- 
noid, or  between  the  latter  membrane  and  the  brain — external  hy- 

*  Brit.  Med.  Journ.,  vol.  i,  1876,  p.  16. 


582  DISEASES  or  children. 

drocephalus.*  Wherever  the  accumulatiOD  takes  place  the  symp- 
toms are  nearly  if  not  quite  alike  in  all  instances.  Where  it  is 
effused,  between  the  arachnoid  and  the  brain,  the  effect  is  to  flatten 
the  convolutions,  if  not  to  obliterate  them,  and  to  expand  and  in- 
crease the  width  of  the  head,  which  also  becomes  elongated,  and 
the  base  of  the  skull  depressed  and  hollowed  out.  When  the  ac- 
cumulation takes  place  in  the  ventricles  the  brain  becomes  thin, 
and  spread  out  so  as  to  be  almost  obliterated ;  and  if  the  fluid 
meets  on  the  two  sides,  the  hemispheres  are  pressed  asunder,  and 
the  distension  stretches  the  pia  mater  so  that  it  can  scarcely  be 
seen;  the  cerebral  tissue  being  infiltrated  by  the  eftused  fluid,  be- 
comes soft  and  pultaceous,  and  otherwise  altered.  The  bones 
entering  into  the  formation  of  the  skull  become  thin  and  friable 
from  the  diminution  of  bony  matter,  and  ossification  is  incomplete 
at  the  anterior  fontanelles,  and  along  the  line  of  the  coronal  suture. 
The  water  may  go  on  increasing  till  the  sutures  separate,  and  the 
ventricles  become  distended  with  as  much  as  three  pints  of  fluid, 
without  any  water  exterior  to  the  brain.  Such  a  case  is  related 
by  Dr.  Underwood. f  The  eftusion  is  greatest  in  the  earlier  months 
of  life,  and  lessens  or  remains  stationary  as  the  child  grows  older. 
When  it  is  congenital,  it  is  due  to  some  morbid  state  of  the  mem- 
branes, or  ventricles  of  the  brain,  and  is  either  observed  at  birth 
or  soon  after. 

The  fluid  consists  chiefly  of  water ;  traces  of  albumen,  phos- 
phate and  carbonate  of  lime,  and  potash  are  found.  It  is  trans- 
parent or  slightly  yellowish,  and  the  specific  gravity  is  lower  than 
the  serum  of  the  blood  from  a  deficiency  of  solid  constituents.  In 
the  well-known  case  of  Cardinal,  who  was  hydrocephalic  from 
infancy,  and  attained  the  age  of  twenty-nine  years,  the  composi- 
tion of  the  fluid  was  found  to  be  : 

Specific  gravity,      .......         1011-38. 

Water, 9S2.6 

Alhnmen,       ..........  6.0 

Chloride  of  sodinin,       ........  7.0 

Soda, 1.4 

Urea  and  osinazome,     ........  3.0 

Sulphuric  acid,  lime,  potash  (a  trace).  

lOOO.OJ 

*  "  Of  200  cases  of  hydrocephalus  I  have  found  100  to  be  of  the  internal  variety,  80 
to  be  oedema  of  the  pia  mater,  10  to  be  cases  of  external  hydroceplialus,  and  10  cases 
of  simple  cerebral  a?dema." — Steiner's  Diiienses  of  Children,  by  Lawson  Tait,  p.  44. 

t  On  the  Diseases  of  (Children,  by  Dr.  Davies,  1846,  p.  373. 

X  Jones  and  Sieveking's  Pathological  Anatomy,  by  Dr.  Payne,  p.  248. 


ON"    DISEASES    OF    THE    BRAIN.  583 

Causes. — The  disease  is  frequently  hereditary,  and  is  met  with 
in  the  families  of  drunkards,  and  those  affected  with  syphilis  and 
consumption.  Children  laboring  under  mesenteric  disease  are 
liable  to  be  attacked,  and  dentition  is  an  exciting  cause,  as  also 
rickets,  by  preventing  or  retarding  the  ossification  of  the  skull ; 
au  attack  of  bronchitis  or  diarrhoea  will  awaken  the  disease  in  a 
child  predisposed  to  it,  and  some  parents  profess  to  trace  it  to  a 
troublesome  catarrh.  Excess  or  deficiency  of  blood  in  the  brain, 
impeding  the  cerebral  circulation;  haemorrhage  into  the  sac  of  the 
arachnoid,  morbid  growths,  or  a  slow  form  of  inflammation,  have 
been  enumerated  as  common  causes.* 

Symjotoms. — Some  enlargement  of  the  child's  head  before  the 
health  begins  to  fail  is  generall}^  the  first  symptom  to  attract 
notice,  but  a  strange  movement  and  unsteadiness  of  the  eyes, 
which  is  set  down  to  gastric  disorder,  may  be  among  the  early  in- 
dications. In  some  instances,  nothing  is  observed  till  a  convul- 
sion happens,  and  from  that  moment  some  marked  signs  ensue. 
The  face  has  an  old  and  shrivelled  look,  and  is  very  small  when 
compared  to  the  size  of  the  head,  the  chin  being  pointed,  and  the 
angles  of  the  lower  jaw  sharp  in  outline.  The  appearance  of  teeth 
is  delayed,  and  children  often  reach  their  first  year  without  any 
traces  of  them.  The  eyes  at  an  early  stage  have  a  slow  rotatory 
movement,  and  the  veins  of  the  head  become  distended,  as  though 
about  to  burst  when  the  child  cries  ;  the  skin  of  the  neck  and 
body  is  loose  and  wrinkled,  and  the  stomach  is  noticed  to  be 
large,  whilst  the  extremities  waste  ;  the  bowels  are  irregular,  being 
sometimes  constipated  and  at  other  times  loose ;  the  motions  are 
light  or  dark  and  oflfensive,  or  clay-colored  and  sticky,  or  they  are 
greenish  and  contain  undigested  matter  like  curdled  milk.  There 
is  apparent  discomfort  about  the  head,  and  the  child  is  constantly 
raising  his  fingers  to  his  eyes,  or  passing  his  hand  across  his  fore- 
head;  he  is  frequently  sick  during  the  day,  and  retains  nothing 
on  his  stomach.  In  some  cases  the  appetite  is  ravenous,  and  the 
child  is  only  quiet  when  he  is  eating ;  in  other  cases  the  appetite 
will  depart  for  days  together.  Having  reached  this  stage  there 
are  striking  changes  to  be  observed  in  the  size  and  shape  of  the 
head.  It  may  have  been  noticed  to  be  larger  at  birth,  or  to 
have  commenced  to  grow  disproportionately  within  a  fortnight  ; 
but  notwithstanding  this,  the  child  may  be  plump  and  healthj'- 

*  West,  on  Diseases  of  Children,  fourth  edition,  p.  117. 


584  DISEASES    OF    CHILDREN. 

looking,  able  to  suck,  and  apparently  well  noarished.  Soon,  how- 
ever, and  frequently  between  the  nintb  and  twelfth  month  (when 
the  mother  leaves  off  suckling,  or  the  diet  is  changed)  nutrition 
is  interfered  with,  and  the  child  begins  to  lose  flesh  and  grow 
weakly.  If  he  is  older,  and  has  been  able  to  walk,  he  totters,  and 
his  legs  cannot  support  him  ;  he  is  wearied  after  exertion,  and 
falls  otf  to  sleep  in  the  daj'time,  and  is  unable  to  support  his  head  ; 
he  is  uneas}^  and  restless  at  night,  and  the  pillow  has  a  wet  circle 
where  the  head  has  laid.  As  the  cranial  bones  yield  to  the  in- 
creasing fluid,  the  veins  of  the  scalp  become  distended,  the  temples 
sink  in,  and  the  forehead  is  arched,  whilst  the  anterior  fontauelle 
is  open,  and  the  frontal  bone  itself  is  only  comj)letely.  ossified  at 
the  lower  half.  In  one  case  under  my  care  two  large  veins  ran 
down  the  groove,  and  when  the  child  cried  they  looked  about  to 
rupture.  As  the  eftusion  advances,  the  parietal  and  frontal  bones 
become  more  separate,  and  their  edges  are  to  be  felt  if  the  disten- 
sion is  moderate  ;  the  eyeball  is  now  prominent  and  thrown  down- 
wards and  forwards,  and  the  sclerotic  between  it  and  the  upper 
eyelid  is  very  prominent,  whilst  the  lower  eyelid  conceals  the  pupil. 
If  the  fluid  increases  rapidly  the  child  may  become  drowsj^  and 
heavy,  and  symptoms  of  compression  ensue,  followed  by  squint- 
ing, convulsions,  irregular  pupils,  and  coma.  In  the  course  of 
hydrocephalus,  before  the  head  is  much  enlarged.  Dr.  West  has 
noticed  in  several  instances,  spasmodic  attacks  of  difficult  breath- 
ing and  crowing  inspiration  like  spasmodic  croup.* 

Treatment. — This  is  a  most  unsatisfactory  disease  to  treat,,  at 
whatever  stage  it  comes  before  us  ;  not,  however,  that  it  is  always 
incurable,  as  instances  of  recovery  are  recorded,  and  hydrocephalic 
children  have  reached  manhood.  Where  the  cerebral  functions 
are  not  seriously  implicated,  and  convulsions  and  paralysis  do  not 
arise  in  the  course  of  the  disease,  we  maj^  hope  for  benefit  from 
treatment  if  we  see  the  case  earlj'-,  and  the  child's  constitution  is 
tolerably  robust. 

The  strenuous  employment  of  mercurial  inunction  for  weeks,  in 
the  shape  of  one  or  two  drachms  of  the  mild  unguentum  h^'drar- 
gyri,  rubbed  in  daily  over  the  shaven  scalp,  has  proved  beneficial. 
It  is  a  plan  recommended  by  Professor  G()lis,  of  Vienna,  and  ap- 
proved of  by  Dr.  West,  f     The  head  is  to  be  kept  constantlj^  covered 

*  Diseases  of  Children,  fourth  edition,  185'J,  p.  120. 
t  Ibid.,  p.  128. 


ON   DISEASES   OF   THE   BRAIN.  585 

and  protected  from  the  cold  by  means  of  a  tightly -fitting  flannel 
cap.  A  quarter  to  half  a  grain  of  calomel  is  to  be  given  twice  a 
day,  unless  diarrhcEa  comes  on,  when  it  is  to  be  discontinued,  and 
inunction  alone  trusted  to.  If  at  the  end  of  six  or  eight  weeks 
no  benefit  results,  diuretics  and  other  remedies  are  to  be  used,  and 
issues  or  blisters  applied  to  the  back  of  the  neck.  A  very  instruc- 
tive and  apparently  hopeless  case  is  recorded  by  Dr.  Underwood.* 
After  leeching  and  purgation,  two  drachms  of  strong  mercurial 
ointment  were  rubbed  in  daily  for  three  weeks,  and  a  powder  con- 
sisting of  a  grain  each  of  squill,  digitalis,  and  calomel  was  given 
night  and  morning.  An  improvement  soon  commenced  and  gradu- 
ally continued ;  the  child  passed  through  dentition  w^ell,  and  at 
twenty-one  years  of  age  was  a  fine  young  man.  Mercury,  like 
other  exhaustive  measures,  must  be  used  with  the  utmost  caution, 
as  prostration  of  strength  is  easily  induced.  If  there  be  restless- 
ness, great  heat,  and  turgescence  about  the  vessels  of  the  head, 
leeches  have,  according  to  some  authors,  been  repeatedly  used 
with  advantage,  but  I  have  had  no  experience  of  the  plan,  never 
having  seen  a  case  in  which  I  should  have  felt  justified  in  employ- 
ing them.  The  treatment  found  most  serviceable  is  to  meet  the 
chief  symptoms  that  are  present  in  each  individual  case ;  if  there 
is  diarrhoea,  or  bronchitis  (not  unfrequent  complications),  it  must 
be  subdued  before  any  active  measure  are  adopted,  or  the  child 
may  die  of  convulsions  or  syncope.  AVhere  the  symptoms  are 
chiefly  cerebral,  and  the  child  is  well  nourished,  mercury  is  best 
tolerated  ;  but  if  there  is  much  w^asting  and  emaciation,  and  the 
pulse  is  feeble  or  irregular,  it  cannot  be  trusted  to.  Looking  at 
the  cases  as  a  wdiole,  I  have  found  small  doses  of  the  hyd.  c.  creta 
of  benefit,  continued  every  night  for  a  week,  and  then  left  oft'  for 
a  short  time  and  resumed  again.  If  the  strength  is  equal  to  it,  I 
prefer  the  sixth  of  a  grain  of  calomel  night  and  morning  for  a  few 
days,  when  the  head  becomes  cooler,  and  congestion  and  sickness 
are  relieved.  Where  mercury  appears  to  be  indicated,  we  may 
obviate  the  dangers  of  depression  by  employing  small  doses  of  the 
solution  of  perchloride  of  mercury  with  the  tincture  of  cinchona. 
As  in  some  other  cerebral  afiections  it  will  be  found  a  valuable 
combination. 

The  iodide  of  potassium  is  another  remedy  on  which  I  repose 

*  Diseases  of  Children,  by  Dr.  Davies,  184G,  p.  374. 


586  DISEASES    OF    CHILDEEX. 

considerable  faith,  in  tlie  management  of  these  cases  ;  it  is  of 
undoubted  value  where  there  is  irritability,  and  the  head  is  slowly 
getting  larger  ;  it  should  be  given  in  small  doses,  one  or  two  grains 
three  times  a  day,  in  a  little  syrup  and  water,  and  then  it  does 
not  disorder  the  stomach,  and  cause  sickness,  as  it  might  do  in 
larger  doses.  I  sometimes  add  a  few  drops  of  sal  volatile  to 
obviate  any  depression.  In  cases  complicated  with  secondary 
syphilis  and  affections  of  the  periosteum  and  joints,  it  is  a  valuable 
alterative,  lessening  irritation  of  the  cerebral  membranes,  and 
promoting  the  absorption  of  chronic  or  inflammatory  effusion.  If 
there  is  restlessness  and  headache,  then  a  few  grains  of  the 
bromide  of  potassium  may  be  advantageously  added  to  it. 

Compression  is  a  remedy  suggested  on  the  view  that  a  certain 
degi'ee  of  pressure  is  conducive  to  health.  It  can  only  be  safely 
employed  when  the  disease  is  chronic  and  stationary,  and  there 
are  no  active  signs  of  cerebral  disturbance.  When  the  child  is 
pale  and  languid,  and  fluctuation  is  distinct  between  the  imper- 
fectly ossified  bones,  the  head  may  be  strapped.  K'arrow  strips  of 
plaster  are  made  to  encircle  the  head  from  one  mastoid  process  to 
the  other,  and  from  the  nape  of  the  neck  to  the  root  of  the  nose. 
If  symptoms  of  pressure  at  the  brain  or  heat  of  head  follow  the 
application  they  must  be  loosened  or  removed  altogether.  Whilst 
this  local  treatment  is  being  carried  out,  the  functions  are  to  be 
stimulated  by  diuretics,  alteratives,  and  an  occasional  purge. 
Preparations  of  iron  and  cod-liver  oil  are  generally  needed,  sooner 
or  later. 

Puncture. — 'This  should  lie  done  at  the  coronal  suture  with  a 
fine  trocar  and  canula  below  the  anterior  fontanelle,  avoiding; 
the  longitudinal  sinus  and  large  veins,  gradually  withdrawing  the 
fluid  and  keeping  up  pressure  on  the  head  as  it  discharges,  lest 
the  pulse  become  weak  and  feeble,  and  the  child  faint.*  I  knew 
of  one  case  in  the  practice  of  a  medical  friend  in  which  a  cure  was 
said  to  have  followed  this  method,  but  I  have  had  no  such  experi- 
ence myself,  and  I  should  be  reluctant  to  adopt  it  unless  all  other 
means  had  failed. 

*   Medical  Times  and  Gazette,  March,  1838. 


EPILEPSY.  587 

CHAPTER    XLIII. 

EPILEPSY. 

Definition  of — Varieties  of:  Epilepsy  proper  or  idiopathic  epih'psy — Epileptic  ver- 
tigo— (Epilepsia  gravior — Le  grand  mal) — Slight  epilepsy — [Epilepsia  mitioi — Lepetit 
mal).  Symptoms:  Of  the  true  or  idiopathic  form — Duration  of  the  jit — Headache 
and  vertigo — Night  alarm  in  children — Character  of  the  urine — Aura  epileptiea — Its 
nature — Association  of  epilepsy  with  chorea — Perversion  of  the  moral  sense — Le  petit 
mal  a  less  severe  and  frequent  form  than  le  grand  mal — Slightness  of  the  spasms. 
Causes  :  Predisposing  and  exciting — Hereditary  influences —  Weakness  of  the  nervous 
system — Syphilis — Rickets — Heart  disease — Phthisis — Tumors  of  brain — Injuries  of 
the  head — Relation  to  carpo-pedal  contractions  {congenital  talipes).  Morbid  Anat- 
omy :  Congestion  of  the  brain — Thrombosis  or  embolism  of  the  small  cerebral  arteries 
— Exalted  sensibility  of  the  medulla  oblongata.  Diagnosis  :  From,  hysteria — Purcdy- 
sis — Convulsions — Difficidty  in  forming  a  differential  diagnosis  between  le  petit  mal  and 
epileptiform  seizures — Resemblance  to  eclampsia — Means  of  distinguishing  the  two  con- 
vulsive attacks — Epileptiform  seizures— Symptoms  and  diagnosis  from  true  epilepsy — 
Resemblance  in  some  cases  to  attacks  of  angina  pectoris.  Prognosis  :  Favorable  in 
early  life  ivhen  the  cause  admits  of  removal—  Unfavorable  when  the  constitution  is  syphi- 
litic or  scrofulous,  or  there  is  a  history  of  nervous  disease.  Treatment  :  During  the 
fit,  and  in  the  interval — Attention  to  the  digestive  organs  and  the  removal  of  all  sources 
of  irritation — Purgative  medicines — Counter-irritation — Necessity  to  observe  a  simple 
diet  and  to  avoid  wine  and  stimulants — Importance  of  hygienic  treatment — Care  in 
education — Bromide  of  potassium,— Iron — Iodide  of  potassium  in  syphilitic  cases — 
Nitro-muriatic  acid — Phosphorus — Ergot — Ammonio-sulphate  of  copper — Oxide  of 
zinc — Prophylactic  measures — Hyoscyamus  and  digitalis  in  epileptiform  seizures. 

It  is  wellnigb.  impossible  to  frame  the  definition  of  a  disease  so 
variable  in  its  manifestations  as  epilepsy,  the  severe  forms  bearing 
but  a  faint  resemblance  to  the  milder  varieties  of  this  afiection. 

Epilepsy  consists  in  the  occurrence  of  fits  at  more  or  less  regular 
intervals  witb  entire  loss  of  sensibility  and  consciousness.  In  its 
severe  form  it  is  accompanied  with  general  convulsions,  and  spas- 
modic contraction  of  the  voluntary  muscles.  It  is  frequently  fol- 
lowed by  deep  sleep  or  coma.  Males  are  said  to  be  more  subject 
to  the  disease  than  females,  but  Russell  Reynolds  considers  the 
two  sexes  about  equally  liable.  Except  when  occurring  in  im- 
beciles, severe  epilepsy  in  children  is  of  very  serious  omen. 

It  is  important  to  remember  that  the  spasmodic  action  may 
vary  from  slight  twitching  of  the  arm  or  leg  to  the  most  severe 
convulsion,  and  that  the  degree  of  consciousness  may  range  from 
mere  bewilderment  and  confusion  of  ideas  to  the  most  profound 
coma. 

Epilepsy  is  divided  into  two  varieties.     1.  Epilepsy  proper,  or 


C88  DISEASES    OF    CHILDREN. 

idiopathic  epilepsy  (Le  grand  mal).  2.  Slight  epilepsy  (Le  petit 
mal). 

Epilepsy  may  be  centric  or  excentric.  When  centric  it  may 
depend  upon  irritable  areas  in  the  brain  ;  irritable  by  some  in- 
herited tendency,  or  some  accidental  injury  or  morbid  growth. 
When  of  excentric  origin  it  may  arise  from  peripheral  irritation, 
as  a  tapeworm  in  the  intestines,  or  some  abnormal  condition  of 
the  viscus.  "Scientifically,  I  should  consider  epilepsies  on  the 
basis  of  each  being  dependent  on  excessive  paroxysmal  discharge 
of  some  part  of  the  cerebral  cortex."* 

The  epileptic  discharge,  though  single,  if  severe  may  produce 
the  same  shock  to  the  rest  of  the  brain,  as  is  the  common  result 
of  a  series  of  rapidly  repeated  fits ;  the  "  status  ejnleptims "  or 
condition  of  complete  prostration  following  a  series  of  repeated 
fits  is  strictly  analogous  to  the  condition  of  exhaustion  produced 
in  the  electric  eel  (Gymnotus)  after  repeated  discharges,  or  the 
condition  of  fish  after  the  explosion  of  gunpowder  or  dynamite  in 
a  pool. 

Death  from  the  first  epileptic  discharge  is  exceedingly  rare. 
When  it  does  so  take  place,  the  brain  and  membranes  are  found 
enormously  congested,  if  the  seizures  are  prolonged.  The  heart  is 
arrested  and  brought  to  a  standstill,  either  from  exhaustion  due 
to  the  violence  of  the  fit,  from  paralysis  of  the  medulla,  or  from 
the  circulation  of  carbonized  blood  producing  asphyxia. 

The  symptoms  of  the  so-called  true  or  idiopathic  form  of 'epilepsy 
are  sudden  loss  of  consciousness,  "  a  paroxysmal  loss  of  conscious- 
ness "  (Hughlings  Jackson),  the  patient  frequently  screams  out  in 
a  loud  voice,  as  if  alarmed  or  terrified,  and  usually  falls  with  his 
face  forward  to  the  ground  in  an  instant  if  standing  up  or  w^alking 
across  a  street  or  room.  He  may,  however,  fall  backwards  or  to 
one  side.  Proximity  to  a  fire  or  water  at  any  moment  may  put 
his  life  in  jeopardy.  He  is  likewise  at  the  risk  of  injuring  himself 
by  coming  in  contact  with  some  hard  body  or  sharp  surface.  Cuts 
and  bruises  are  common  enough  under  these  circumstances.  Ter- 
ror and  a  sense  of  fear  frequently  precede  an  attack.  In  the  seizure 
the  child  throws  his  arms  about  and  kicks  violently,  the  muscles 
being  tense  and  powerfully  contracted;  the  convulsions  may  be 
general,  but  as  a  rule,  one  side  of  the  body  is  more  affected  than 

*  Lectures  on  tlie  Diagnosis  of  Epilepsy,  by  Hughlings  Jackson,  M.D.,  The  Lancet, 
1879,  p.  43. 


EPILEPSY.  589 

the  other;  the  eyes  are  wild  and  fixed,  or  so  hidden  by  the  upper 
lids  that  the  sclerotic  is  only  exposed.  The  pupils  are  usually  di- 
lated and  insensible  to  light,  but  at  an  early  stage  they  are  often 
contracted,  and  of  variable  size  during  the  continuance  of  the 
paroxysms.  The  pulse  may  be  so  variable  that  it  is  scarcely  percep- 
tible, or  it  is  not  altered  from  health,  whilst  the  heart  is  felt  to  be 
violently  beating  and  the  carotids  are  equally  active.  The  expres- 
sion is  greatly  distorted  ;  the  face  is  pallid  at  tirst,  from  tonic  con- 
traction of  the  vasoii>otor  nerves,  but  it  soon  becomes  livid,  and 
the  superiicial  veins,  including  those  of  the  head,  are  turgid,  and 
the  muscular  coats  of  the  bloodvessels  are  involved  in  spasm. 
Sometimes  mucus  mixed  with  blood  issues  from  the  mouth.  Small 
extravasations  of  blood  on  the  surface  of  the  face  and  forehead  are 
occasionally  seen  resembling  petechiiE.  The  tight  closure  of  the 
jaws  often  causes  the  patient  to  bite  the  tongue  or  the  under  lip. 
The  contraction  of  the  flexor  tendons  is  always  great,  the  fingers 
being  clenched  in  the  palms  of  the  hands,  the  foot  arched,  and  the 
toes  bent. 

The  insensibility  may  be  so  profound  that  the  patient  cannot  be 
roused  by  any  means  at  our  command,  and  even  reflex  action  can- 
not be  excited  in  severe  cases  by  tickling  the  feet,  or  irritating  the 
conjunctiva.  When  the  paroxysm  has  subsided,  the  skin  is  bathed 
in  perspiration,  consciousness  returns,  and  the  patient  may  seem 
none  the  worse  for  the  seizure;  but  in  piany  cases  there  follow 
profound  sleep,  and  on  awaking  the  child  may  be  torpid,  and  his 
memory  and  ideas  confused  for  a  day  or  two.  lie  complains  of 
frontal  headache,  and  the  featu-res  are  so  congested  and  bloated  as 
to  be  almost  characteristic.  "  Headache  and  vertigo  are  the  two 
forms  of  disturbance  the  most  frequently  complained  of  by  epilep- 
tics."* Headache  is  common  both  before  and  after  the  seizure. 
Dr.  Sieveking  met  with  it  in  56  out  of  101  cases.  He  speaks  of  it 
as  "  Cephalalgia  e-pileptiformis^^'^  and  says,  although  the  pain  may 
aflect  any  part  of  the  head  it  chiefly  attacks  the  vertex.  In  the 
cases  I  have  observed  there  have  been  the  usual  characters  of  con- 
gestive headache  from  excitement  of  the  circulation  and  fulness 
of  the  cerebral  vessels.:}:     Sometimes  the  contents  of  the  bladder 


*  A  System  of  Merlicine,  article  E]iile]w,  by  J.  Eiissell  Reynolds,  M.D.,  vol.  ii, 
p.  313. 

f  On  Epilepsy,  1861,  p.  50. 

X  On  Headaches,  by  W.  II.  Day,  M.D.,  1879. 


690  DISEASES    OF    CHILDEEX. 

and  bowel  are  passed  involuntarily  during  the  fit.  The  tonic  con- 
vulsions continue  for  a  few  minutes,  and  then  pass  away,  leaving 
the  muscles  more  or  less  flexed  and  extended.  Sleep  may  continue 
for  some  hours  afterwards,  the  muscles  being  completely  relaxed  or 
tremulous.  The  fit  usually  lasts  two  or  three  minutes  altogether, 
but  it  may  continue  for  a  quarter  of  an  hour.  "  The  first  or  te- 
tanic period  is  generally  the  shortest,  lasting  from  a  few  seconds 
to  half  a  minute  or  one  minute  ;  while  that  of  the  clonic  convul- 
sions is  the  longest,  and  lasts^  from  three  to  six  minutes."  (Al- 
thaus.)  In  some  cases  of  epilepsy  the  patient  is  no  sooner  free 
from  one  fit  than  another  supervenes.  When  this  happens,  the 
brain  sufters  from  these  repeated  shocks,  and  in  the  intervals  of 
the  paroxj'Sms  the  child  is  torpid  and  prostrated.  There  may  be 
several  fits  in  the  course  of  the  twenty-four  hours,  or  the  interval 
may  extend  over  months  and  years.  "  The  number  of  attacks  in 
a  given  time  ranges  between  very  wide  limits,  from  two  to  two 
thousand  in  a  year ;  but  half  the  cases  are  found  to  have  a  rate  of 
recurrence  ranging  from  one  attack  in  fourteen  to  one  in  thirty 
days."* 

"  What  is  called  night-alarm  or  nightmare  in  children  is  often 
an  incomplete  epileptic  attack.  The  children  go  to  bed  and  sleep 
in  the  usual  manner,  but  after  a  time  scream,  endeavor  to  get  out 
of  bed,  stare  at  some  imaginary  object,  break  out  into  a  profuse 
perspiration,  fall  back  exhausted  and  relaxed,  and  go  to  sleep  again. 
Such  attacks  may  be  repeated  several  times  in  the  night,  and  the 
little  patients  have  no  recollection  of  them  on  waking  in  the  morn- 
ing."f  A  child  aged  three  years,  sufl'ering  from  rickets  and  cere- 
bral exhaustion,  was  under  my  care  in  November,  1879,  and  the 
nurse  found  him  night  after  night  in  the  condition  described,  but 
he  never  had  a  genuine  convulsion  or  epileptic  paroxj-sm.  Bro- 
mide of  potassium  and  henbane  relieved  the  symptoms. 

In  some  cases  the  urine  contains  an  abundance  of  phosphates, 
alternating  with  an  equal  quantity  of  lithates.  "  Frequently  there 
is  an  excess  of  phosphates ;  oxalates  are  often  seen ;  and  I  have 
repeatedly  found  the  urine  of  epileptics  exhibit  persistently  so 
large  a  quantity  of  urea,  that,  on  the  addition  of  equal  parts  of 

*  Russell  Reynolds,  op.  cit.,  p.  315. 

t  Lectures  on  Diseases  of  the  Nervous  System,  by  J;ilius  Altliiius,  M.D.,  Medical 
Examiner,  Feb.  7th,  1878,  p.  112. 


EPILEPSY.  591 

nitric  acid,  the  whole  of  the  liquid  was  almost  solidified  by  con- 
version into  urea."* 

An  epileptic  seizure  does  not  always  commence  in  the  same  way. 
Before  the  attack,  in  some  instances,  there  is  pain  in  the  stomach, 
nausea,  or  vomiting,  headache,  and  restless  sleep.  In  other  cases 
there  are  pain  in  the  praecordial  region,  and  palpitation  of  the 
heart,  bright  colors  appear  before  the  eyes,  there  are  noises  in  the 
ears,  and  nervous  apprehension.  The  patient  often  looks  wild  or 
vacant,  and  the  mouth  and  lips  are  in  constant  movement.  If  the 
tongue  is  protruded  there  may  be  seen  on  its  surface  a  foamy 
saliva,  which  is  not  infrequent  among  adults  who  suffer  from 
nervous  disorders.  "  Children  particularly  show  the  alarm  they  ex- 
perience b}'  running  to  and  clinging  to  their  nurses  and  mothers."! 
A  peculiar  feeling  of  cold,  or  tingling,  or  numbness,  or  vaporish 
sensation,  creeping  from  the  lower  extremities,  is  felt  along  the 
spine  to  the  back  of  the  head  (termed  the  "<:mr<2 "),  when  the 
patient  becomes  insensible,  and  falls  down  in  the  lit. 

The  aura  ejnlejptica  is  a  curious  physiological  phenomenon  which 
indicates  the  approach  of  the  paroxysm.  It  is  a  premonitorj'- 
symptom,  occurring  in  about  one-half  the  cases,  and  is  subject  to 
much  variation  in  its  character.  Sometimes  it  is  motor  in  its 
origin — convulsions  seizing  on  a  certain  set  of  muscles,  as  those  of 
one  arm,  or  leg,  or  foot,  or  finger.  Many  years  ago,  a  young  lady 
came  under  my  notice,  where  the  paroxysm  was  preceded  by  in- 
cessant tremor  of  the  right  leg.  She  called  out,  "  I  am  going  to 
have  ague  1"  and  then  the  fit  followed.  There  was  probably  vaso- 
motor disturbance,  and  a  sense  of  chilliness  at  the  same  time  ex- 
tending upwards  from  the  limb  to  the  brain.  Some  anras  seem  to 
affect  the  nerves  of  special  sense,  as  when  offensive,  strong,  or 
disagreeable  odors  excite  a  paroxysm,  or  flashes  of  light  are  seen 
before  the  eyes.  Occasionally  the  aura  may  be  visceral,  as  when 
it  affects  the  stomach,  heart,  or  intestines.  Any  sudden  shock,  as 
calling  aloud,  tying  a  ligature  round  the  limb,  or  giving  a  stimu- 
lant, may  arrest  a  seizure  even  when  the  aura  is  present. 

Dr.  Ilandfield  Jones  mentions  the  case  of  an  epileptic  boy,  13 
years  of  age,  in  which  the  fits  began  with  a  sinking  sensation  of 
the  stomach,  then  giddiness  and  falling  down,  but  there  was  no 
unconsciousness.  After  a  "fright"  he  got  well-marked  chorea, 
but  he  was  free  from  epilepsj'.    The  author  remarks  that  "the 

*  On  Epilepsy,  by  E.  H.  Sieveking,  M.D.,  1861,  p.  119.  f  Ibid.,  p.  19. 


592  DISEASES   OF   CHILDREN". 

transmutation  of  the  malady  into  chorea  is  a  point  of  much  in- 
terest, marking  the  affinity  which  subsists  between  the  several 
neuroses."'*'  The  aura  or  reflex  action  in  such  a  case  would  prob- 
ably travel  to  the  medulla  oblongata  by  means  of  the  sympa- 
thetic and  pneumogastric  nerves.  There  is  a  similar  relation  to 
asthma. 

Ifot  unfrequeutly  the  disease  is  preceded  by  a  voracious  appetite 
or  constipation,  in  others,  on  the  contrary,  by  a  total  dislike  of 
food.  In  most  cases  there  is-  no  notice  of  the  fit  before  it  occurs. 
Agitation  and  excitement  are  instantly  followed  by  swimming  in 
the  head,  the  room  appears  to  go  round,  and  the  patient  falls 
down.  * 

An  epileptic  fit  may  be  preceded  or  followed  by  spitefulness, 
anger,  and  violence.  The  child  is  shy,  fretful,  suspicious,  wilful, 
disobedient,  or  morose.  Dr.  Sieveking  has  observed  "  thieving 
propensities  and  other  mischievous  tendencies,  such  as  setting 
fire  to  dwellings."  Dr.  Althaus  has  recorded  a  case,  in  a  boy  of 
7,  who  had  regular  attacks  of  destructiveness,  tearing  sheets, 
blankets,  clothes,  and  everything  within  his  reach.  '■'■  After  a 
particularly  bad  outbreak  he  was  put  in  a  strait  waistcoat,  and 
managed  to  tear  it  to  pieces  with  his  teeth. "f  In  another  case 
under  his  care,  a  girl  of  9  was  a  "  fearful  liar,"  stole  money,  and 
was  daring  and  defiant.  A  girl,  9  years  of  age,  was  brought  to 
me  by  her  mother,  in  1872,  who  was  in  the  habit  of  suddenly 
rushing  at  her  sisters  and  brothers  before  the  paroxysm,  and 
biting  them,  after  the  fashion  of  a  ferocious  dog  which  had  been 
teased  and  irritated.  The  arms  of  one  sister  showed  iudentations 
caused  by  the  patient's  teeth, 

The  petit  mal  is  a  less  severe  and  frequent  form  of  epilepsy,  con- 
sisting in  giddiness  and  confusion  of  ideas,  or  sudden  and  transient 
loss  of  consciousness,  accompanied  with  sjuiiptoms  of  faintness  or 
of  syncope.  There  is  slight  convulsive  movement  of  the  facial 
muscles,  eyes,  and  hands,  or  may  be  not  even  this,  followed  by 
stupor  and  sleep.  The  patient  may  stagger,  and  even  fall  down, 
or  may  exhibit  such  a  wild  and  vacant  look  that  a  bystander 
thinks  a  fit  is  about  to  happen.  "To  prevent  a  possible  misunder- 
standing, let  me  remark  that  the  terms  '  slight '  and  '  severe  '  refer 
to  quantity  of  manifestation,  not  to  gravity  of  the  case,  the  slight 

*  On  Fnnci'nnal  Nervous  Disorders,  1870,  p.  293. 
t  Medical  Press  and  Circular,  July  IGtli,  1879,  p.  45. 


EPILEPSY.  593 

seizures  are  the  worst  for  mind."*  When  the  convulsions  are 
severe,  the  insensibility  complete,  and  there  is  biting  of  the  tongue 
and  foaming  of  the  mouth,  the  diagnosis  of  epilepsy  is  easy  enough, 
but  epileptic  vertigo  with  partial  suspension  of  reason  is  apt  to 
perplex  us  in  diagnosis.  In  some  of  these  attacks  the  spasm  is 
scarcely  obvious.  The  respiration  may  be  momentarily  suspended, 
and  the  face  at  first  pallid  becomes  livid,  whilst  the  urine  is  fre- 
quently discharged  during  the  seizure.  "A  boy,  10  years  of  age, 
had  been  subject  to  fits  for  two  years.  At  the  first  they  were  so 
slight  that  his  mother  said  they  thought  he  was  in  a  '  deep  study  ;' 
he  used  to  sit  '  as  if  he  were  thinking.'  The  attack  was  only  of 
a  few  seconds'  duration,  and  no  alteration  of  complexion  was 
noticed.  Later  on  in  his  fits  he  would  turn  up  his  eyes — slight 
spasm  of  very  small  muscles.  Later  still,  there  was,  besides  this, 
occasional  shaking  of  the  body  (imitated  before  me  by  tremor).  I 
saw  one.  Whilst  sitting  the  boy  blinked  his  eyes ;  he  did  not  alter 
in  color;  he  then  drew  in  a  deep  breath,  and  rapidly  all  was  over. 
The  paroxysm  was  so  sudden  and  short  that  I  could  not  make 
any  special  investigations.  Attacks  of  epilepsy  may  be  so  slight 
that  strangers  sitting  opposite  a  patient  at  dinner  may  observe 
nothing,  although  there  is  absolute,  though  transient  loss  of  con- 
sciousness."f  These  slight  seizures  may  come  and  go,  and  then 
be  replaced  by  the  severe  forms  of  epilepsy.  "  Le  petit  mal  "  may 
occur  with  or  without  spasm.  Li  the  former  there  is  a  sudden  or 
temporary  loss  of  consciousness  lasting  for  a  few  seconds,  and 
then  passing  off  without  the  patient  knowing  that  anything  has 
happened.  In  the  latter  there  may  be  slight  spasm  of  the  facial 
or  laryngeal  muscles,  or  the  spasm  may  be  brief  and  slightly 
involve  the  whole  voluntary  muscles  of  the  body,  "  The  most 
common  combination  and  degree  of  symptoms  may  be  thus  de- 
scribed,— a  feeling  of  giddiness,  faintness,  or  discomfort ;  slight 
twisting  of  the  neck,  with  anxious  lachrymose  expression  of  the 
face,  dilatation  of  the  pupils  and  pallor,  accompanied,  or  quickly 
followed  by  entire  loss  of  consciousness,  which  lasts  for  two  or 
three  seconds  ;  the  patient  becoming  himself  again  after  making 


*  Hughlings  Jackson,  op.  cit.,  p.  42. 

t  Dr.  Hughlings  Jackson,  On  the  Diagnosis  of  Epilepsy,  The  Lancet,  1879,  vol.  i, 
p.  43. 

38 


594  DISEASES    OF    CHILDREN. 

a  few  sighing  sounds,  but  feeling  faint  and  bewildered,  and  often 
perspiring  freely."* 

Tbe  causes  that  predispose  to  epilepsy  are  various.  The  disease 
can  often  be  traced  to  hereditary  influence,  the  parents  or  some 
member  of  the  family  having  suftered  from  it ;  or  there  is  a  history 
of  insanity  or  some  other  neurosal  aftection — such  as  an  originally 
weak  or  susceptible  condition  of  the  nervous  tissue,  liable  to 
morbid  action.  Long-continued  debility  and  gastric  irritation, 
or  anv  source  of  exhaustion,  as  chronic  diarrhoea,  albuminuria, 
masturbation,  etc.,  are  among  tbe  factors  which  lead  to  the  epi- 
leptic paroxysm.  Hereditary  sj^philis  is  another  cause.  Rickets 
would  also  appear  to  be  a  cause,  just  as  it  is  of  eclampsia.  "At 
least  three-fourths  of  the  cases  of  epilepsy,  dating  from  infancy, 
are  believed  to  be  the  consequence  of  rickety  convulsions."f  The 
relation  between  heart  disease  and  epilepsy  is  also  very  close,  as 
out  of  sixty-six  cases  observed  b}^  Dr.  Gowers,  in  which  the  two 
diseases  were  conjoined,  in  twenty-five  there  was  mitral  or  aortic 
disease.^  He  thinks  the  cardiac  disturbance  is  due  to  one  of 
three  causes.  1.  Irregular  action.  2.  Simple  dilatation.  3. 
Valvular  disease.  These  several  conditions  would  appear  to  be 
either  the  consequence  of  the  epileptic  paroxysm,  which  puts  a 
violent  strain  on  the  heart,  or  the  fits  arise  from  the  cardiac 
afi'ection.g 

In  a  boy,  9  years  of  age,  who  came  under  ray  care  in  1875, 
there  were  the  symptoms  of  pulmonary  consumption.  I  have 
observed  the  connection  before,  though  not  often  enough  to  justify 
me  in  saying  that  it  is  more  than  casual.  Phthisis  is  far  more 
common  than  epilepsy,  and  when  the  two  diseases  occur  together 
there  is  probably  a  state  of  the  nervous  system  which  readily 
invites  an  epileptic  paroxysm.  The  patient  had  been  losing  fiesh 
and  strength,. was  much  wasted,  and  coughed  chiefly  at  nights. 
Whilst  under  treatment  a  fit  occurred  for  the  first  time,  lasting 
an  hour  and  a  half  This  was  followed  by  haemoptysis  to  nearly 
a  pint,  with  the  physical  signs  of  tubercular  disease  of  the  lungs. 
These  various  influences  reduce  the  bodily  health  in  such  a  manner 

*  A  System  of  Medicine,  article  Epilepsy,  by  J.  Russell  Reynolds,  M.D.,  vol.  ii, 
p.  303.; 

t  On  Some  of  the  Causes  of  Epilepsy,  by  J.  R.  Gowers,  M.D.,  Medical  Society's 
Proceedings,  vol.  iv,  p.  259. 

t  Ibid.,  p.  259. 

§  Heart  Disease  and  Epilepsy,  Brit.  Med.  Journ.,  1877,  vol.  ii,  p.  730. 


EPILEPSY.  595 

as  to  enfeeble  the  nervous  system  and  determine  an  outbreak  in 
susceptible  subjects. 

The  exciiing  causes  are  fright  and  terror,  outbreaks  of  passion, 
masturbation,  anaemia,  and  intestinal  worms.  "  A  boy,  13  years 
of  age,  was  frightened  a  year  ago  by  a  snake ;  a  month  after  the 
fright  he  had  a  strong  epileptic  fit.  He  is  now  a  confirmed  epi- 
leptic ;  his  manner  is  sullen  and  dogged,  he  refuses  to  take  his 
medicine,  '  because  he  does  not  like  it ;'  he  has  on  several  occa- 
sions threatened  his  sister's  life,  by  brandishing  a  knife ;  he  pre- 
sents a  physiognomy  indicative  of  mental  aberration,  and  will 
have  to  be  removed  to  an  asylum.  There  is  no  family  history  of 
neurosis,  and  the  mental  condition  appears  to  have  been  produced 
by  fright."*  In  a  child  aged  4,  who  came  under  my  care  in  1875 
for  epilepsy,  the  fits  commenced  at  the  eleventh  month,  during 
dentition ;  another  fit  recurred  at  two  years  of  age,  and  there  was 
an  interval  of  two  years  before  the  next  came  on.  The  child  had 
enlarged  cervical  glands,  and  a  severe  eruption  of  impetigo.  In 
another  case  under  my  care  in  1876,  a  girl,  10  years  of  age,  had 
an  occasional  epileptic  seizure,  which  followed  scarlet  fever  three 
years  previously;  still  there  was  no  kidney  disease. 

It  is  also  to  be  borne  in  mind  that  there  may  be  a  tumor,  or  an 
abscess,  or  a  spicula  of  bone  growing  from  the  skull  and  irritating 
the  membranes. 

An  accidental  blow  may  drive  down  a  spicula  of  the  brittle  inner 
table  of  the  skull,  or  produce  a  spot  of  localized  inflammation  and 
adhesion  which  may  lead  to  repeated  epileptic  fits.  "  A  boy  re- 
ceived a  violent  blow  on  the  head  from  a  cricket  bat.  He  did  not 
appear  to  suffer  any  inconveniences  from  the  injury  until  ten  or 
eleven  years  afterwards,  when  he  became  subject  to  paroxysmal 
attacks  of  headache,  associated  with  extreme  vertigo,  clearly  of 
an  epileptic  character.  He  eventually  had  a  succession  of  severe 
attacks  of  epilepsy,  which  continued  for  a  period  of  five  years. 
He  ultimately  died  in  a  violent  epileptic  paroxysm. "f  Many  cases 
of  epilepsy  are  traceable  to  blows  and  injuries  of  the  head. 

There  is  a  close  relationship  between  the  convulsive  aft'ections  of 
children  and  congenital  talipes.     Operations  for  the  cure  of  these 


*  Phenomena  accompanying  Epilepsy,  by  Dr.  Buzzard,  Brit.  Med.  Journ.,  1877, 
vol.  ii,  p.  729. 

t  On  Obscure  Diseases  of  the  Brain  and  Mind,  by  Forbes  Winslow,  M.D.,  1S60, 
p.  674. 


596  DISEASES   OF   CHILDREN. 

deformities  have  been  followed  bj  epilepsy.  Just  as  in  some  adult 
women,  the  subjects  of  hysteria,  distortion  of  a  limb  will  follow 
repeated  paroxj-sms,  demanding  mechanical  treatment  till  the 
irritation  subsides.  Mr.  Brodhurst  records  the  following  instruc- 
tive case:  "  February,  1852,  I  divided  the  tibial  tendons  and  the 
tendo  Achillis  of  a  strong  plethoric  infant,  fourteen  months  old, 
for  the  removal  of  congenital  varus.  Both  feet  were  nearly  equally 
distorted.  I  had  scarcely  commenced  the  operation,  when  the 
child,  crying  violently,  was  seized  with  a  fit  ;  and  I  then  learned 
that,  when  seven  months  old,  the  child  had  whooping-cough,  which 
was  followed  by  a  succession  of  slight  fits  ;  and  that,  at  intervals, 
on  coughing  or  crying  violently,  the  fits  recurred.  The  feet  were 
after  some  months  perfectly  restored,  and  the  supports  were  at 
length  removed  and  discontinued.  Seventeen  months  after  the 
operation  the  child  again  had  a  fit,  when  both  feet  Avere  drawn 
into  the  same  distorted  positions  as  at  birth.  The  father  of  this 
child  was  epileptic.""^ 

Mr.  William  Adams  has  pointed  out  that  it  is  only  in  cases  of 
rigid  muscles  that  epilepsy  occurs,  the  muscles  being  rather  spas- 
modic and  spastic  than  flaccid,  as  in  the  truly  paralytic  class,  where 
they  take  on  fatty  degeneration.!  The  author  describes  a  most 
interesting  case  of  a  boy,  14  years  of  age,  who  fell  under  his  care, 
for  rigid  muscular  contraction  of  both  legs,  and  deformity  of  the 
feet.  The  affection  commenced  from  infancy.  "  He  had  been  for 
several  years  subject  to  epileptic  fits,  the  continuance  of  which 
had,  to  a  slight  extent,  weakened  his  mental  vigor,  although  his 
bodily  health  remained  good.  At  the  time  I  saw  him  the  fits 
occurred  regularly  once  a  month.":}: 

Morbid  Anatomy. — The  brain  is  sometimes  congested,  and  the 
vessels  are  too  full  of  blood,  but  the  pathological  changes  may  be 
entirely  negative,  there  being  no  relation  between  them  and  the 
violent  symptoms  that  have  been  noticed  during  the  seizure.  Dr. 
Hughlings  Jackson  thinks  there  is  thrombosis  or  ernbolism  of  the 
small  arteries  in  most  cases  ;  and  he  bases  this  opinion  on  the  fact 
of  having  found  epileptiform  seizures  common  in  those  patients 
sufiiering  from  valvular  disease  of  the  heart.  He  is  of  opinion 
that  there  is  evidence  to  show  that  the  pathology  of  the  disease  is 
more  "arterial "  than  "  nervous. "§    There  are  many  cases  in  which 

*  On  Club-foot,  1856,  p.  57.  f  Ibid.,  1873,  p.  61. 

X  Ibid.,  p.  392.  §  Op.  cit.,  p.  113. 


EPILEPSY.  597 

more  or  less  hemiplegia  is  induced  by  epilepsy.  "  In  these  cases  I 
do  not  doubt  that  there  is  embolism  or  extravasation.  The  fre- 
quent presence  of  external  extravasation  justifies  the  view  that  a 
similar  condition  occurs  in  the  brain.  The  hemiplegia  is  some- 
times very  evanescent "  (Sieveking). 

Schroeder  van  der  Kolk  thinks  that  the  loss  of  consciousness  in 
epilepsy  is  due  to  the  excited  action  of  the  ganglionic  cells  in  the 
medulla  oblongata,  which  extends  its  influence  to  the  vasomotor 
nerves  of  the  brain ;  and  he  believes,  moreover,  with  Kussmaul, 
that  in  an  epileptic  fit  the  whole  brain  participates  more  or  less 
in  the  change ;  the  commencement  of  the  fit  or  of  the  discharge 
is. to  be  referred  to  the  exalted  sensibility  of  the  medulla  oblon- 
gata.* 

Diagnosis. — True  epilepsy  in  its  severe  form,  as  it  ordinarily 
occurs  in  childhood,  is  not  difiicult  of  diagnosis  ;  the  complete  in- 
sensibility, the  brief  duration  of  the  fit,  the  general  convulsions, 
and  the  absence  of  stertorous  breathing  and  paralysis  render  it 
impossible  to  confound  it  with  hysteria  or  apoplexy.  The  milder 
cases,  in  which  there  is  confusion  of  the  mind,  without  complete 
loss  of  consciousness,  where  there  is  reverie  or  forgetfulness,  and 
peculiar  sensations  are  complained  of,  the  diagnosis  is  not  so  easy 
to  establish. 

Between  le  petit  mal  and  epileptiform  seizures  the  diagnosis  is 
often  impossible. 

Eclampsia  is  the  most  likely  disease  to  be  mistaken  for  epilepsy, 
the  convulsive  paroxysms  being  in  both  instances  much  alike 
There  are,  however,  a  few  distinctive  features  which  may  be  con- 
sidered diagnostic.  Convulsions  are  most  common  in  infancy. 
They  occur  in  connection  wdth  dentition  and  are  repeated  fre- 
quently ;  they  are  sometimes  observable  at  the  beginning  of  acute 
febrile  disorders,  and  particularly  scarlet  fever,  which  does  not 
apply  to  epilepsy.  The  latter  aiiection  is  often  very  sudden,  the 
child  at  the  time  of  the  seizure  being  in  apparently  good  health, 
whilst  convulsions  are  often  preceded  by  some  previous  illness. 
In  convulsions  the  movements  are  more  confined  to  the  eyes  and 
facial  muscles  than  to  the  limbs.  The  frequency  of  the  convulsive 
attacks  disturbs  the  nervous  centres,  interferes  with  the  respira- 
tion, and  terminates  fatally  in  asphyxia.  Children  seldom  die  in 
an  epileptic  attack. 

*  On  the  Spinal  Cord  and  Medulla  Oblongata,  New  Syd,  Soc,  1859,  p.  230. 


598  DISEASES   OF   CHILDEEX. 

Epile'ptiform  seizures  resemble  the  true  form  of  epilepsy  in  some 
respects,  and  diiier  from  it  in  others.  The  distinctive  features,  as 
pointed  out  so  clearly  by  Dr.  Hughlings  Jackson,  are  chiefly  in 
respect  to  consciousness  and  convulsion.  In  true  epilepsy  con- 
sciousness is  lost  the  first  thing,  or  very  soon  after  the  commence- 
ment of  the  seizure,  and  the  convulsions  are  also  general  from  the 
beginning.  Epileptiform  seizures  usually  begin  with  spasm  of  one 
hand  or  foot  (or  side  of  the  thorax,  as  I  have  observed),  conscious- 
ness is  lost  later  on,  or  not  at  all  if  the  seizure  is  slight ;  the  con- 
vulsions are  local  or  one-sided  before  they  become  general.  When 
consciousness  is  not  entirely  abolished  the  symptoms  are  said  to  be 
frequently  induced  by  some  organic  disease  of  the  brain,  as  a  cyst 
or  tumor,  which  is  not  the  case  with  true  epilepsy.*  A  case  is 
related  by  Trousseau,  where  a  little  boy  who  died  from  epilepti- 
form seizures,  had  tubercles  in  the  brain. f 

A  very  excitable  and  passionate  girl,  nine  years  of  age,  was  ad- 
mitted into  the  Samaritan  Hospital  under  my  care,  with  epilepti- 
form seizures,  December  30th,  1878.  The  fi.ts  resembled  the  petit 
mal  where  the  seizures  are  slight.  She  never  fell  down,  although 
she  would  stagger  as  if  about  to  fall.  Before  the  fit  happened  she 
was  drowsy,  strange  and  absent  in  her  manner ;  she  could  not 
speak  distinctly  for  some  hours  before  the  attack,  and  there  was  a 
difficulty  in  engaging  her  in  conversation.  To  prevent  the  possi- 
bility of  falling  she  was  laid  on  a  bed,  when  she  soon  became 
gradually  convulsed,  the  right  arm  first,  then  the  right  leg,  and 
then  the  other  leg  in  precisely  the  same  order.  If  the  eyeballs 
were  touched  there  was  no  reflex  excitement  induced  ;  there  was 
no  biting;  of  the  touo-ue,  and  no  foamino-  of  the  mouth.  The  face 
underwent  no  change  in  color,  and  the  pulse  averaged  eighty  per 
minute.  The  head  shook  tremulously  from  side  to  side,  and  the 
eyes  were  closed  ;  the  tremor  would  sometimes  continue  for  a 
quarter  of  an  hour,  then  it  would  subside,  and  the  child  fall  asleep 
for  some  hours  before  a  return  to  consciousness.  The  arms  and 
upper  portion  of  the  trunk  of  the  body  were  chiefly  affected.  The 
patient  would  have  as  many  as  three  attacks  in  one  day,  then  not 
another  seizure  for  a  week ;  and  then  an  interval  of  seven  weeks 
elapsed.  Every  fit  was  of  the  same  character,  but  stronger  each 
time.     It  was  not  influenced  by  diet,  or  any  cause  that  could  be 

*  Lectures  on  the  Diagnosis  of  Epilepsy,  The  Lancet,  1879,  vol.  i,.  p.  42. 
J  Clinical  Medicine,  1807,  vol.  i,  p.  62. 


EPILEPSY.  599 

ascertained.  Bromide  of  potassium  in  gradually  increasing  doses, 
phosphorus,  cod-liver  oil,  etc.,  gave  no  relief.  Thirty  minims  of 
the  tincture  of  henbane,  gradually  increased  to  sixty,  in  half  an 
ounce  of  camphor-water  three  times  a  day,  completely  arrested  the 
fits  during  the  time  she  took  the  remedy.  A  return  of  the  fits 
came  on  when  it  was  omitted,  and  again  departed  on  resuming  it. 

The  followino;  is  a  case  of  interest  in  which  the  "aura  "was 
cardiac.  The  seizures  were  of  a  doubtful  nature  at  first,  and  I  was 
inclined  to  regard  them  as  due  to  angina  pecioris,  but  they  ter- 
minated in  true  epilepsy.*  E.  B — ,  set.  6,  was  admitted  under  my 
care  into  the  Samaritan  Hospital  on  December  6th,  1876,  suffering 
from  what  her  mother  called  "  spasm  of  the  heart  when  she 
awoke  in  the  morning."  She  was  a  nervous  and  timid  child,  and 
easily  moved  to  tears.  In  infancy  she  sufiered  from  convulsions, 
and  ever  since  then  had  been  periodically  subject  to  these  seizures. 
From  the  age  of  two  years  the  attacks  had  been  more  confirmed 
and  regular,  coming  on  about  once  a  month.  Six  weeks  previous 
to  her  admission  she  was  found  insensible  in  the  street  by  a  police- 
man, and  she  so  continued  for  three  hours.  The  attacks  began 
with  pain  over  the  cardiac  region,  and  a  tremulous  and  throbbing 
action  of  the  heart,  followed  by  pallor  and  faintness;  the  eyes 
were  wild  and  staring,  and  if  no  one  was  near  to  support  her  she 
w^ould  fall.  Partial  consciousness  was  preserved.  The  heart's 
sounds  were  normal,  and  the  rhythm  regular.  Pulse  100  ;  respi- 
ration 24;  temperature  normal.  The  urine  was  of  high  specific 
gravity  (1034),  clear,  acid,  non-albuminous,  but  containing  much 
urea. 

After  being  under  observation  for  three  weeks,  the  report  states 
that  every  other  morning  she  had  an  attack  on  waking  about  7 
A.M.,  which  lasted  from  three  to  five  minutes.  There  was  tremor 
of  the  facial  muscles,  which  were  partially  convulsed.  She  was  put 
on  a  milk  diet,  and  ordered  a  mixture  containing  phosphoric  acid 
and  strychnia.  'No  fit  occurred  for  a  month,  and  then  in  my  pres- 
ence she  suddenly  screamed  out,  put  one  hand  over  her  heart,  and 
the  other  against  the  right  wall  of  the  chest,  both  being  firmly 
clenched.  She  did  not  fall.  Her  eyes  were  fixed  and  staring,  and 
she  understood  nothing  that  was  addressed  to  her.  Her  face  was 
slightly  reddened,  and  the  lips  were  compressed,  as  if  in  pain. 
The  heart's  action  was  rather  tumultuous  and  thumping,  and  the 

*  A  good  many  cases  of  angina  pectoris  are  certainly  a  form  only  of  partial  epi- 
lepsy.— Trousseau's  Clin.  Med.,  vol.  i,  1867,  p.  65. 


600  DISEASES    OF    CHILDREN. 

pulse  was  weak  and  intermitted  every  fourtli  beat.  The  nurse, 
who  had  seen  her  in  several  attacks,  had  always  felt  the  heart 
thump  and  beat  against  the  thorax  at  the  time  of  the  seizure.  A 
week  later,  without  any  previous  intimation,  she  had  another  and 
more  severe  seizure.  It  began  with  general  convulsive  movements 
of  the  upper  and  lower  limbs,  working  of  the  facial  muscles  and 
eyelids,  foaming  at  the  mouth,  but  no  biting  of  the  tongue ;  she 
tossed  and  kicked  about  incessantly  for  nearly  two  hours,  and  then 
she  fell  into  sound  sleep  for  nine  hours.  On  awaking  she  was  par- 
tially conscious,  and  seemed  to  recognize  the  nurse.  Every  day 
following,  for  the  next  week,  there  was  a  fit  of  a  similar  character. 
Tincture  of  digitalis  in  five-minim  doses  was  now  ordered  three 
times  a  day,  and  then  the  fits  entirely  ceased  for  the  next  month. 
She  left  the  hospital  on  March  4th,  with  directions  to  continue 
the  remedy  which  had  apparentlj^  kept  the  fits  in  abeyance. 

Prognosis. — This  is  favorable  when  epilepsy  arises  from  any 
cause  which  admits  of  removal,  as  worms  in  the  intestinal  canal, 
dentition,  etc. ;  but  when  it  happens  in  children  over  tw^elve  j^ears 
of  age,  and  the  constitution  is  syphilitic  or  scrofulous,  or  there  is 
a  family  history  of  nervous  disease,  then  the  complaint  may  be 
incurable.  The  aspect  of  epilepsy,  however,  it  must  be  admitted, 
has  been  profoundly  modified  by  the  introduction  of  the  bromides 
into  our  pharmaceutical  armamentaria,  and  cases  now  yield  to 
their  peculiar  action,  over  which  other  drugs  have  no  controlling 
or  curative  influence  whatever.  If  we  have  approached  towards 
a  correct  knowledge  of  the  pathology  and  causes  of  epilepsy,  and 
our  treatment  is  far  more  successful  than  formerl}^,  it  still  rests  on 
an  insecure  and  empirical  basis.  There  is  no  remedy  even  at  the 
present  time  that  can  be  positively  termed  a  specific,  or  that  can 
.lay  claim  to  cure  the  afffection. 

Treatment. — In  the  management  of  epilepsy  the  treatment  di- 
vides itself  into  two  stages.  1.  During  the  fit.  2.  In  the  in- 
terval. 

1.  During  the  fit  it  is  advisable  to  put  the  child  on  a  bed,  if 
there  be  one  at  hand ;  to  loosen  all  articles  of  clothing,  especially 
about  the  neck,  and  to  insert  a  piece  of  wood,  or  India- imbber,  or 
even  a  fold  or  two  of  linen  rag  between  the  teeth  to  prevent  biting 
of  the  tongue.  Cold  may  be  applied  to  the  head,  and  a  sinapism 
to  the  nape  of  the  neck.     "When  the  seizure  has  terminated  the 


EPILEPSY.  GOl 

child  is  usually  disposed  to  sleep,  which  may  he  permitted,  and 
when  it  wakes  up,  light  nourishment  may  be  allowed. 

2.  In  the  interval  of  the  fit  the  aim  should  be  to  remove  all 
sources  of  irritation,  as  that  caused  b^^-  dentition,  worms  in  the 
intestinal  canal,  constipation,  congestion  of  the  brain,  general 
plethora,  mental  emotion,  as  fits  of  anger  and  passion.  If  there 
be  evidence  of  plethora  and  fulness  of  the  cerebral  vessels,  a  non- 
nitrogeuous  diet,  sleeping  on  a  hard  bed,  and  purgative  medicines 
will  be  demanded,  especially  at  an  early  stage.  They  should  be 
strong  enough  to  be  eftectual  without  diminishing  vital  power; 
rhubarb  and  senna,  tartrate  of  soda,  taraxacum,  or  castor  oil.  In 
some  cases  a  little  Hunyadi  Janos  or  Friedrichshall  water  may  be 
advantageously  given  in  sweetened  milk. 

Admitting  that  it  is  of  the  utmost  importance  to  diminish  or 
remove  the  morbid  sensibility  and  congestion  of  the  medulla 
oblongata,  all  agents  that  excite  this  must  be  rigidly  excluded, 
and  sources  of  irritation  removed  in  whatever  part  of  the  body 
they  may  be  discovered. 

Except  for  very  special  reasons  mercury  is  not  to  be  adminis- 
tered in  epilepsy.  Where  thci^e  is  a  suspicion  of  worms,  or  the 
liver  is  sluggish,  and  the  chief  secretory  organs  are  at  fault,  a 
calomel  purge,  by  acting  as  a  derivative  and  washing  away  foul 
matters,  will  prove  serviceable. 

Counter-irritation  at  the  back  of  the  neck  may  be  necessary  in 
some  exceptional  cases ;  but  I  have  never  done  more  in  this  way 
than  to  apply  a  stimulating  liniment  to  the  back  of  the  neck, 
which  is  sometimes  serviceable,  as  the  compound  camphor  lini- 
ment and  cantharidis,  or  the  compound  liniment  of  mustard,  or 
the  liniment  of  turpentine  and  acetic  acid. 

A  highly  nitrogenized  diet,  by  increasing  the  exploding  ten- 
dency of  the  irritable  areas,  is  very  hurtful,  and  it  cannot  be  too 
much  insisted  on  to  watch  children  most  carefully  in  this  respect. 
The  imposition  on  the  digestive  organs  of  more  work  than  they 
can  comfortably  discharge,  or  the  accumulation  of  indigestible 
matters  in  the  intestinal  tract,  impairs  the  quality  of  the  blood 
and  predisposes  to  the  epileptic  paroxysm.  Dr.  Merson  has  made 
some  interesting  investigations  on  the  efl'ects  of  diet  in  epilepsy. 
He  put  twelve  patients,  so  suffering,  on  a  nitrogenous  diet,  and 
twelve  on  a  farinaceous  diet,  for  four  weeks.  At  the  end  of  this 
time  he  reversed  the  plan,  those  taking  farinaceous  food  exchanging 


602  DISEASES   OF   CHILDREN. 

it  for  nitrogenous,  and  vice  versa.  At  the  end  of  another  four 
weeks  the  patients  resumed  their  ordinary  dietary.  IsTo  decided 
advantages  resulted  from  following  either  diet,  though  there  was 
a  slight  advantage  in  favor  of  the  farinaceous  regimen.  The 
nitrogenous  plan  seemed  to  produce  more  dulness,  stupidity, 
dreaminess,  and  listlessness.  The  mental  condition  improved 
under  the  farinaceous  diet,  the  patients  being  lively  and  intelligent, 
again  becoming  dull  and  stupid  when  the  diet  was  nitrogenous, 
whilst  the  number  of  fits  increased.  A  higher  rise  of  temperature 
was  also  observed  under  the  latter  diet.  The  urine  contained 
more  urea  and  salts,  and  was  of  higher  specific  gravity  nnder  the 
nitrogenous  diet  than  under  the  farinaceous.  The  number  of  fits 
was  somewhat  less  under  the  latter.  On  the  whole,  the  writer 
considers  there  are  fair  grounds  for  believing  that  a  farinaceous 
diet  is  likely  to  be  less  hurtful  than  a  nitrogenous  one.*  I  think 
this  view  of  the  question  will  be  generally  conceded,  and  that  we 
are  right  in  enforcing  a  plain,  simple,  and  nutritious  diet  in  epi- 
leps3^  Milk  and  cocoa  should  be  taken  in  preference  to  tea  and 
coftee,  and  wine  and  stimulants  strictly  forbidden. 

The  hygienic  treatment  of  epilepsy  in  early  life  claims  our  first 
attention.  We  can  scarcely  commit  a  graver  mistake  than  to 
overlook  the  lesson  it  teaches  us,  that  all  drugs  hitherto  selected 
to  cure  the  malady  occupy  a  subordinate  rank  to  those  rules  and 
habits  of  life  which  must  be  observed  in  the  maintenance  of 
health.  I  strongly  entertain  the  conviction  that  whatever  con- 
duces to  the  general  health,  and  keeps  the  various  functions  of 
the  hodj  in  proper  working  order,  does  during  the  period  of 
growth  exert  such  a  beneficial  influence  on  the  nervous  system, 
as  to  arrest  or  cure  that  peculiar  condition  of  it  which  invites 
the  epileptic  discharge. 

When  the  disease  is  threatening,  or  it  has  developed  itself,  our 
first  duty  is  to  inquire  into  the  habits  and  life  of  the  child  ;  to 
remove  it  if  possible  from  a  bad  atmosphere  to  a  healthy  one, 
where  light  takes  the  place  of  darkness ;  to  see  that  the  air  is 
pure  and  invigorating ;  the  sleeping  apartment  lofty  and  commo- 
dious ;  and  to  surround  it  with  all  those  influences  which  elevate 
its  mental  and  moral  tone.  The  children  of  the  poor  shut  up  in 
the  ill-ventilated  apartments  of  London  have  an  indifterent  chance 
of  recovery,  and  we  often  witness  temporary  alleviation  in  those 

*  On  the  Influence  of  Diet  in  Epilepsy,  The  West  Riding  Asylum  Lunatic  Reports, 
1875,  p.  23. 


EPILEPSY.  003 

cases  wliicli  are  sent  into  the  country.  Impure  air  retards  the 
physical  strength  and  prevents  the  child,  if  old  enough,  from 
getting  that  amount  of  exercise  which  diverts  the  mind  and 
pleasurably  engages  it;  whilst  the  appetite  improves  and  digestion 
is  strengthened.  A  seaside  residence  and  high  mountain  air  have 
proved  of  incalculable  benefit. 

Above  all,  overexcitement  of  the  intellect,  in  any  child  who 
comes  of  epileptic  parents,  or  who  has  once  had  a  fit,  should  be 
carefully  guarded  against.  The  effort  to  accomplish  the  routine 
life  of  school  is  a  sufficient  stimulus  in  itself  to  the  cerebral  circu- 
lation, and  if  there  is  anxiety  added  to  it,  or  too  much  pressure  is 
put  upon  the  child's  intellect,  the  nervous  power  becomes  ex- 
hausted, and  an  epileptic  paroxysm  is  the  consequence.  Mothers 
who  have  the  bringing  up  of  excitable  or  epileptic  children,  should 
in  this  age  of  pressure  and  progress  encourage  mental  rest.  Dur- 
ing the  early  years  of  life,  when  physical  growth  is  most  active, 
and  the  brain  is  undergoing  expansion  and  rapid  changes,  we 
cannot  too  strongly  insist  on  preserving  the  strength  of  the  intel- 
lectual powers,  that  they  be  not  overtaxed  in  any  way. 

Bromide  of  potassium  is  the  great  remedy  in  the  treatment  of 
epilepsy,  and  it  is  about  the  only  drug  on  which  we  can  rely  for 
the  mitigation  of  the  symptoms,  if  not  for  the  cure  of  the  disease. 
It  lessens  the  peculiar  excitability  of  the  nervous  centres,  and 
probably  diminishes  the  amount  of  blood  circulating  in  the  brain, 
which  may  obviate  the  tendency  to  congestion,  and  so  ward  off 
the  paroxysms  when  this  condition  is  a  factor  in  the  complaint. 
As  a  sedative  it  controls  the  spasmodic  character  of  the  disorder, 
and,  by  promoting  sleep,  gives  the  brain  rest.  It  is  especially 
indicated  if  the  epilepsy  is  traceable  to  masturbation,  or  to  excite- 
ment of  the  sexual  organs.  Its  action  varies  with  different  per- 
sons. In  some  it  not  only  lengthens  the  intervals  of  the  seizures 
and  renders  them  milder,  but  it  cures  the  disease.  The  drug  ought 
to  be  continued  for  months,  or  even  for  a  year,  after  the  epilepsy 
has  ceased,  the  doses  and  the  frequency  of  their  repetition  being  va- 
ried from  tin:ie  to  time  according  to  circumstances.  When  omit- 
ted in  some  cases,  the  attacks  return  with  greater  obstinacy  than 
characterized  the  original  seizures.  In  a  few  cases  this  remedy 
fails  altogether.  "  Bromides  appear  less  useful  in  growing  girls 
and  youths  than  in  those  who  have  reached  adult  age.""- 

*  Kussell  Eeynolds,  op.  cit.,  p.  323. 


604  DISEASES   OF    CHILDREN. 

The  dose  may  be,  to  commeDce  witli,  small,  and  increased 
gradually  till  the  fits  yield,  or  the  interval  is  lengthened.  A 
child  at  five  years  of  age  may  begin  with  five  grains  three  times 
a  day,  increasing  the  dose  gradually  to  fifteen  grains  in  the  same 
space  of  time.  It  is  important  to  be  aware  that  large  doses  of 
this  drug  can  be  borne  by  children  without  bad  results.  "Twenty 
and  thirty  grains  have  been  no  uncommon  dose  to  reach  in  pa- 
tients of  from  eight  to  ten,  suflering  from  epileptic  seizures,  and 
in  them  I  have  never  observed  any  sjmiptoms  of  bromism."*  It 
may  be  given  in  plain  water  with  a  little  syrup,  or  in  some  bitter 
infusion.  When  the  seizures  take  place  during  the  night,  a  full 
dose  of  the  bromide  should  be  given  justJ)efore  bedtime. 

A  boy  six  years  of  age,  who  was  epileptic  from  birth,  was 
relieved  by  the  injection  of  fifteen  grains  of  hydrate  of  chloral  by 
the  rectum,  after  the  inhalation  of  chloroform  and  nitrate  of  amyl 
had  failed.  The  fits  occurred  once  a  fortnight,  and  both  in  this 
case  and  in  other  cases  related,  the  drug  was  sometimes  given  by 
the  mouth  and  sometimes  by  the  rectum.  The  fits  were  thus 
controlled  in  number  and  severity,  the  pulse  became  softer,  the 
respiration  free,  and  sleep  was  induced. f 

Iron  may  sometimes  be  combined  with  bromide  of  potassium  if 
there  is  great  anaemia,:]:  but  though  it  may  seem  to  be  indicated, 
it  does  not  agree  well  with  epileptics.  It  may  improve  the  gen- 
eral health,  but  it  aggravates  the  epilepsy  (Hughlings  Jackson 
and  Brown-Sequard).  Iron  given  alone  is  of  very  questionable 
value,  even  when  there  is  great  ansemja.  It  must  be  combined 
with  antispasmodics.  Still,  I  think  it  should  never  be  overlooked 
that  very  deteriorated  blood  cannot  maintain  the  functions  of  the 
nervous  system  in  a  healthy  state,  and  for  this  reason  alone  a  mild 


*  Dr.  Farqiiliarson,  On  Some  Points  in  the  Art  of  Prescribing  for  Children,  Brit. 
Med.  Journ.,  vol.  ii,  1877,  p.  439. 

t  On  the  Therapeutic  Value  of  Chloral  Hydrate  in  Epileptic  Convulsions;  by  J.  A. 
Wallis,  M.D.,  The  West  Riding  Lunatic  Asylum  Med.  Eeports,  1875,  p.  257. 
X  Formula  82 : 

R.    Ferri  et  amni.  citr.,      .......     gr.  xvj 

Potass,  bromid.,  ...         .         .         .         .         •     B'j 

Syrupi, .^^iij 

A(piam  ad 5iv. — M. 

A  tablesjjoonful  tliree  times  a  day.     For  cliildren  from  six  to  twelve  years  of  age. 


EPILEPSY.  605 

and  soluble  preparation  of  iron  may  be  of  service  in  some  cases. 
The  stronger  preparations  are  too  stimulating. 

The  rapid  loss  of  blood  may  excite  the  epileptic  state,  just  as 
animals  die  of  convulsions  who  are  bled  to  death.  Ligature  of 
the  carotids  in  rabbits,  as  performed  by  Sir  A.  Cooper,  produced 
convulsions,  so  that  it  seems  necessary  to  maintain  the  cerebral 
circulation  as  near  as  possible  at  a  normal  standard.  Ansemia  and 
congestion  of  the  brain  are  both  excitants  of  the  epileptic  par- 
oxysm, but  blood  may  be  very  deficient  in  quantity  and  poor  in 
quality  without  producing  epilepsy ;  some  other  factor  being 
needed  to  invite  it. 

Where  there  is  a  syphilitic  taint,  mercury  or  iodide  of  potassium 
will  be  necessary. 

When  there  is  dyspepsia  or  intestinal  disturbance,  and  the 
urine  contains  oxalates,  pale  lithates,  or  phosphates,  nitromuriatic 
acid  should  be  given  alone,  or  in  combination  with  some  bitter  in- 
fusion. 

Phosphorus  is  a  good  remedy  where  nervous  exhaustion  is  well 
marked. 

Ergot  is  useful  in  ten  to  thirty  minim  doses  of  the  liquid  ex- 
tract, given  three  times  a  day.  It  lessens  the  hypersemia  of  the 
cerebral  bloodvessels,  and  causes  them  to  contract. 

Ammonio-sulphate  of  copper  is  another  remedy  sometimes 
spoken  of,  but  I  have  had  no  experience  of  it.  Dr.  Russell  Rey- 
nolds speaks  favorably  of  oxide  of  zinc.  Bromide  of  zinc  has 
been  given  successfully  in  epilepsy  by  M.  Charcot,  either  in  the 
form  of  pill  or  syrup,* 

In  regard  to  prophylactic  measures,  an  epileptic  seizure  may 
sometimes  be  arrested  by  the  application  of  pressure,  as  by  a 
bandage  between  the  "  aura  "  and  the  brain,t  or  by  encircling  the 
throat  with  a  fold  of  linen  rag  dipped  into  hot  water.  This  re- 
laxes the  cervical  vessels,  and  also  favors  the  removal  of  spasm 
from  the  vessels  of  the  brain, 

A  slight  stimulant  given  to  a  child  just  before  the  seizure  ap- 
proaches may  possibly  ward  it  off",  as  is  the  case  with  some  adults. 

I  have  known  epileptiform  seizures  yield  to  thirty  minims  of 
tincture  of  hyoscyamus  in  camphor-water  three  times  a  day,  after 


*  Brit,  Med.  Jonni.,  vol.  ii,  1877,  p.  732. 
t  Russell  Eeynolds,  op.  cit.,  326. 


606  DISEASES    OF    CHILDEEN. 

bromide  of  potassium  had  failed.    Digitalis  with  bromide  of  potas- 
sium is  also  most  useful.* 

When  epilepsy  is  associated  with  cardiac  disturbance,  neurosal 
or  organic,  digitalis  may  be  given  with  advantage,  provided  there 
is  no  hypertrophy  or  aortic  regurgitation.  We  should,  in  fact, 
observe  the  same  rales  in  prescribing  it  as  in  those  cases  of  heart 
disease  uncomplicated  with  epilepsy. 


CHAPTER   XLIV. 

INFANTILE    CONVULSIONS    OR   ECLAMPSIA. 

GE^JERAI<  AND  Partial:  Lw-ard  convulsions  (Status convulsivus).  Symptoms:  Subject 
to  irnich  variation — Sometimes  preceded  by  heat  of  head  and  febrile  disturbance — State 
of  the  jmpils—Carpo-pedal  contractions.  Causes  :  Predisposing  and  exciting — JVerti- 
ous  susceptibility  and  family  inheritance — Rickety  constitution  and  delayed  dentition — 
Indigestion — Diarrhrex  and  improper  food— Heat  and  cold, — Foreign  bodies  in  the 
brain  or  other  organs — The  eruptive  fevers,  especially  scarlet  fever — Renal  disease — Re- 
lation to  laryngismus.  TERMINATIONS:  In  asphyxia— Shock  and  syncope.  Pa- 
thology AND  Morbid  Anatomy  :  Congestion  of  brain  and  membranes — Paralysis. 
Treatment  :  Removal  of  cause  if  possible — Aperient  medicines  or  enema —  Warm 
bath — Chloroform  inhalation — Bromide  of  potassium — Hydrate  of  chloral — When  de- 
pending on  specific  poison,  as  scarlet  fever,  elimination  shouldbe  encouraged  and  animal 
food  avoided  if  urcemia  threaten — Tonics  and  sedatives  after  the  fits. 

Night  terrors — Mental  disorder — Melancholia — Nervous  and  hysterical  symptoms — Cretin- 
ism— Idiocy — Backwardness — Imbecility. 

The  brain  is  said  to  undergo  such  rapid  development  during 
the  first  few  years  of  life,  that  by  the  completion  of  the  second 
year,  when  the  first  dentition  is  over,  its  size  is  doubled ;  and  by 
the  seventh  year  it  has  nearly  attained  its  maximum  bulk,  though 
its  growth,  according  to  Solly,  is  not  completed  till  the  twentieth 
year.  An  organ  growing  so  rapidly,  and  receiving  one-fifth  of  the 
whole  mass  of  blood  circulating  through  the  body  when  every 
other  orgxin  is  in  process  of  active  development,  must  be  liable  to 
resent  excitement  of  any  kind,  and  to  take  on  morbid  action.    The 

*  Formula  83 : 

K.  Tinct.  digitalis, ti^xx-n^xl 

Potass,  broinid.,  .         .         .         .         .         .         .         •     BU 

Syrup,  aurant.,     ........     g'U 

Aquain  ad    .........     .5iv. — M. 

A  tablespoonful  three  times  a  day.     For  children  from  six  to  twelve  years  of  age. 


INFANTILE   CONVULSIONS    OR    ECLAMPSIA.  G07 

bones  of  the  cranium  are  thin  in  early  life,  the  brain-substance  is 
elastic,  and  the  cerebral  vessels  do  not  derive  from  it  the  same  de- 
gree of  support  as  do  those  of  the  adult,  and  therefore  increased 
arterial  action,  as  from  cardiac  excitement,  violent  coughing,  or 
the  sthenic  action  consequent  on  inflammatory  fevers,  subjects  its 
vessels  to  fulness.  The  development  of  the  brain  is  so  great,  that 
whilst  on  an  average  in  man  its  entire  weight  constitutes  1  in  36 
to  the  rest  of  the  body,  in  the  average  of  mammalia  it  is  only  1 
to  186.*  When  it  is  considered  that  the  arterial  anastomoses  are 
so  free,  it  is  evident  that  any  obstruction  to  the  supply  of  blood 
through  the  chief  vessels  of  the  brain  or  their  branches,  may 
exert  such  an  influence  on  the  nervous  matter  as  to  suspend  or 
derange  the  activity  of  its  functions. 

In  consequence  then  of  this  highl}-  developed  state  of  the  nervous 
system,  convulsions  or  eclampsia  are  amongst  the  most  frequent 
and  dangerous  diseases  which  attack  the  nervous  system  in  infant 
life.  The  mortality  resulting  from  them  ranks  before  that  of 
the  great  majority  of  other  diseases,  including  atrophy,  the  specific 
eruptive  fevers,  pulmonary  disorders,  and  affections  of  the  larynx 
and  trachea.  Up  to  the  age  of  five  years  the  mortality  is  enor- 
mous; but  after  the  age  of  nine  it  is  considerably  diminished. 
Males  are  more  subject  to  the  disease  than  females. 

Convulsions  consist  in  spasmodic  action  and  relaxation  (inde- 
pendent of  the  will)  of  the  voluntary  muscles,  accompanied  by  un- 
consciousness. In  many  respects  th.ey  resemble  epilepsj',  from 
which  indeed  they  cannot  invariably  be  distinguished.  "  Symp- 
tomatic or  idiopathic  epilepsy  is  only  recurring  eclampsia,  and 
eclampsia  is  merely  accidental  or  transitory  epilepsy  "  (Trousseau). 
Convulsions  constitute  in  reality  a  wide  term,  since  they  occur  in 
various  conditions  when  the  lesions  are  entirely  different ;  as,  for 
instance,  in  epilepsy,  tetanus,  chorea,  and  tubercle  of  the  brain. 
They  may  happen  to  delicate  infants  when  the  supply  of  blood  to 
the  brain  is  deficient. 

Symptoms. — The  attack  occurs  either  suddenly,  or  is  preceded 
by  symptoms  showing  undue  excitability  of  the  nervous  system. 
The  infant  is  feverish  for  a  day  or  so  before  the  seizure,  the  head 
is  hot,  the  appetite  is  gone,  and  there  is  thirst.  It  is  restless  and 
starts  in  its  sleep,  or  wakes  up  frightened  ;  the  eyes  are  heavy 
and  have  a  peculiar  rolling  motion  ;  the  respiration  is  irregular  ; 

*  Carpenter's  Human  Physiology,  Sth  edit.,  p.  737. 


608  DISEASES    OF   CHILDREN. 

the  thumbs  are  turued  inwards  and  the  wrists  bent.  In  some  cases 
the  child  is  in  its  usual  health  when  it  is  suddenly  seized ;  in 
others  the  attack  comes  on  during  some  eruptive  disease,  or  during 
dentition.  On  the  approach  of  the  attack  the  child  utters  a 
scream  and  looks  vacant ;  the  ball  of  the  eye  is  tremulous,  and 
the  eyeball  is  turned  upwards,  inwards,  or  downwards,  so  as  in 
some  cases  to  hide  the  iris  entirely.  The  pupils  may  be  contracted 
or  dilated,  or  one  may  be  contracted  and  the  other  dilated ;  but 
there  is  no  uniformity  with  respect  to  this  symptom.  The  facial 
muscles  are  also  involved  in  the  paroxysm,  and  the  countenance 
becomes  terriblj'  distorted  and  hideous ;  there  is  frothing  at  the 
mouth  and  closure  of  the  jaws  ;  whilst  the  head  is  thrown  back- 
wards or  to  one  side,  the  cervical  and  dorsal  muscles  are  rigid,  and 
the  lower  extremities  are  agitated  and  the  feet  flexed  inwards. 

Causes. — These  may  be  predisposing  and  exciting.  Among  the 
former,  is  a  nervous  susceptibility  inherited  from  the  parents. 
This  may  not,  however,  have  actually  manifested  itself  in  the  form 
of  convulsions,  but  there  is,  perhaps,  a  neurosal  diathesis  on  one 
or  both  sides,  and  on  inquiry  it  will  usually  be  found  that  in  other 
members  of  the  family  there  is  a  history  of  convulsions  or  chorea 
in  childhood,  and  of  neuralgia,  asthma,  insanity,  or  other  disturb- 
ance of  the  nervous  system  in  adult  life.  The  children  of  mothers 
who  have  had  convulsions  themselves  in  infancy  are  stated  by 
Trousseau  to  be  liable  to  a  similar  affection.  He  quotes  a  remark- 
able case  by  Dr.  Duclos,  of  Tours.  "  The  case  is  that  of  a  woman, 
34  years  of  age,  the  sister  of  ten  children,  six  of  whom  died  of 
convulsions,  and  who  herself  had  had  frequent  attacks  of  eclampsia 
up  to  the  age  of  seven ;  these  had  left  behind  slight  deviation  of 
the  mouth  and  ptosis  of  the  left  upper  eyelid.  This  woman  had 
ten  children,  who  all  had  convulsions  ;  six  had  died,  live  in  the 
first  two  years,  and  one  when  three  years  old.  Iler  3'oungest, 
whom  she  brought  to  meat  the  Necker  Hospital,  was  a  little  girl, 
six  months  old ;  three  months  previously  she  had  had  a  first 
attack,  which  had  lasted  about  ten  minutes,  and  which  her  mother 
ascribed  to  her  having  given  the  breast  to  the  child  immediately 
after  a  fit  of  passion,  as  the  convulsions  occurred  on  the  ensuing 
day.  Death  took  place  three  months  afterwards  from  cerebro- 
meningitis."*     Trousseau  also  mentions  the  case  of  a  child  who 

*  TrouHsoau's  Clin.  Med.,  18G7,  vol.  i,  p.  343. 


INFANTILE   CONVULSIONS   OR   ECLAMPSIA.  609 

had  eclampsia  from  the  nurse  going  into  a  fit  of  passion  a  moment 
before  giving  him  the  breast.* 

Dentition  has  generally  been  believed  to  be  the  chief  cause  of 
infantile  convulsions,  but  recent  researches  do  not  corroborate  this 
notion.  It  is  more  in  consonance  with  facts  to  say,  that  the  ex- 
citability of  the  nervous  centres  is  excessive  during  the  first  year 
of  life,  and  that  slight  causes,  which  leave  hardly  any  effects  in 
adults,  are,  in  the  period  of  the  first  dentition  and  weaning,  liable 
to  o;ive  rise  to  convulsive  seizures. 

Convulsions  are  frequently  to  be  found  in  children  who  are 
rickety,  and  in  whom  dentition  is  delayed.f  Here  convulsions 
have  a  reflex  origin.  They  may  occur  in  connection  with  chronic 
hydrocephalus  and  struma,  where  the  head  is  large  and  the  fon- 
tanelles  are  open.  They  are  not  infrequently  associated  with 
laryngismus.  A  rickety  child,  eighteen  months  old,  came  under  my 
care  in  1876 ;  she  had  only  three  teeth  ;  as  many  as  six  fits  took 
place  in  the  twenty-four  hours,  each  fit  lasting  about  a  minute. 
The  face  was  drawn  to  the  right  side  and  much  distorted,  the 
pupils  were  dilated.  After  each  fit  the  child  became  conscious,  but 
fell  asleep  afterwards.  Sleep  and  coma  are,  however,  more  com- 
mon after  epilepsy. 

When  severe  eruptions  of  the  scalp  in  children  are  dried  up  too 
quickly,  convulsions  sometimes  follow.  I  have  seen  a  few  cases. 
A  child,  ten  months  old,  came  under  my  care  in  1875,  with  eczema 
of  the  entire  head,  the  whole  scalp  being  covered  with  crusts, 
from  beneath  which  an  irritating  discharge  escaped.  When  the 
healing  process  was  nearly  completed,  and  the  discharge  had 
ceased,  the  child  had  a  succession  of  convulsions,  which  termi- 
nated fatally  in  three  days. 

Convulsions  may  be  met  with  in  infants  at  the  breast,  who  suf- 
fer from  frequent  vomiting  and  diarrhoea.  The  fits  subside  when 
the  functions  of  digestion  are  set  in  proper  order.  Convulsions 
may  also  be  observed  in  children  who  are  thriving  and  doing  well, 
whose  bowels  are  regular,  and  whose  motions  are  of  proper  consis- 
tence. Whatever  tends  to  weaken  the  system,  such  as  improper 
and  insufficient  food,  or  profuse  diarrhcea,  by  lowering  the  nutritive 
functions,  will  exhaust  the  strength,  and  by  depriving  the  nervous 

*  Ibid.,  p.  345. 

f  Of  61  eclamptic  children,  56  were  rickety  (Dr.  Gee,  St.  Bart.  Hosp.  Reports,  vol. 
iii). 

39 


610  DISEASES   OF   CHILDREN. 

system  of  its  proper  support,  weaken  it  and  render  it  more  un- 
stable. Hence  it  is  that  diarrhoea  in  weakly  children  may  readily 
provoke  a  seizure.  Losses  of  blood  are  equally  productive  of  an 
attack.  Diseases  of  the  intestinal  canal,  and  especially  worms  in 
the  bowels,  are  common  causes.  Hot  weather  may  so  lower  and 
exhaust  the  system  as  to  bring  on  convulsions.  Cold,  hy  paralyz- 
ing the  vasomotor  sj^stem,  may  equally  provoke  an  attack,  and 
exposure  to  night  air  is  particularly  dangerous  in  this  respect. 

Convulsions  are  stated  by  Trousseau  and  others  to  have  been 
set  up  by  a  pin  or  needle,  or  a  fragment  of  the  inner  table  of  the 
skull,  sticking  into  the  membranes  of  the  brain,  or  even  into  other 
internal  organs.  Blisters,  burns,  and  scalds  have  likewise  caused 
them.  They  may  occur  during  the  eruptive  fevers  and  acute  pul- 
monary affections.  In  these  cases  the  febrile  disturbance  induces 
hypersemia  of  the  brain  and  membranes,  the  vessels  carrying  too 
much  blood  to  the  head,  and  that  at  an  elevated  temperature,  as 
maybe  witnessed  in  some  cases  of  meningitis.  When  convulsions 
occur  in  association  with  whooping-cough,  organic  disease  of  the 
heart,  and  intestinal  torpor,  the  cerebral  vessels  are  probably  in  a 
state  of  hypersemia.  Cerebral  anaemia,  from  loss  of  blood  and  de- 
ficient vital  power,  may  equally  bring  on  these  fits.  Convulsions 
may  arise  when  the  urine  is  albuminous  from  desquamative 
nephritis,  as  in  scarlet  fever,  or  in  measles  and  small-pox,  where 
the  blood  is  poisoned,  and  the  renal  organs  cannot  eliminate  their 
morbid  products. 

One  peculiar  form  of  convulsions  in  children  is  that  knoAvn  as 
eclampsia  nutans  or  salaam  convulsions,  because  it  resembles  the 
obeisance  of  an  Oriental  before  his  superior.  It  consists  of  a 
bending  of  the  head  and  body  forwards  with  great  rapidity  for  a 
certain  period,  when  it  ceases.  During  the  time  the  child  seems 
bewildered,  but  as  soon  as  the  convulsions  cease  its  intellect  be- 
comes clear.  While  they  are  present  the  mental  and  bodily  health 
seem  impaired,  but  no  permanent  effect  in  either  has  been  observed. 
They  are  not  associated  with  any  known  changes  in  the  nervous 
system.  They  may,  however,  in  certain  cases,  be  the  precursor  of 
epilepsy,  especially  if  they  are  persistent. 

Terminations. — Death  may  be  due  to  asphyxia  from  the  violence 
of  the  seizure,  or  from  shock  and  syncope,  but  recovery  is  usual. 
Dr.  West  says  :  "  Where  the  convulsions  recur  rapidly  the  prog- 
nosis is  exceedingly  bad,  and  this  is  worse  in  children  of  three  or 


INFANTILE   CONVULSIONS   OR   ECLAMPSIA.  Gil 

four  years  old  than  in  young  infants,  as  indicating  a  greater  dis- 
turbance, and  one  less  likely  to  pass  away."  He  goes  on  to  say, 
"  Far  less  hopeless  are  cases,  with  which  we  also  meet  occasionally, 
of  the  exceedingly  frequent  recurrence  of  convulsions,  five,  ten,  or 
more  taking  place  every  day,  for  days  or  weeks  together.  Such 
attacks  are  seldom  or  never  met  with  after  the  completion  of  den- 
tition. The  danger  to  life  seems  to  lessen  with  the  frequency  of 
their  recurrence,  but  there  is  danger  lest  they  should  end  by  their 
becoming  habitual;  while,  further,  there  seems  to  be  a  very  de- 
cided relation  between  the  liability  to  convulsions  in  early  infancy, 
and  the  development  of  epilepsj-  in  subsequent  childhood."* 

Morbid  Avatomy. — After  death  dissection  discloses  congestion  of 
the  brain  and  membranes,  effusion  into  the  ventricles  or  sac  of 
the  arachnoid,  and  hsemorrhagic  points  may  sometimes  be  noticed 
on  section  of  the  hemispheres  ;  congestion  of  the  spinal  cord  is 
also  present.  These  morbid  changes  are  the  consequences  of  the 
convulsions;  just  as  they  occur  in  epilepsy,  they  are  not  the  cause, 
but  the  result  of  the  malady.  In  a  single  paroxysm  such  lesions 
are  of  no  material  importance,  but  where  the  convulsions  recur 
frequently,  then  the  change  that  takes  place  in  the  cerebral  tis- 
sues may  result  in  such  a  degree  of  congestion  or  extravasation 
as  to  end  in  some  paralytic  affection.  Anatomical  lesions  cannot, 
however,  be  invariably  discovered  on  the  most  careful  dissection, 
and  when  they  are  found  they  appear  to  be  rather  a  consequence 
than  a  cause  of  the  seizure.  It  should  not  be  forgotten  that 
convulsions  are  not  incompatible  with  an  anaemic  state  of  the 
brain. 

Treatment. — This  does  not  differ  materially  from  that  of  epilepsy 
and  some  other  allied  disorders,  but  convulsions  cannot  be  dealt 
with  alike  in  all  cases.  The  first  step  is  to  ascertain,  if  possible, 
their  cause,  before  aiming  at  their  removal.  In  the  seizure  the 
child  should  be  surrounded  by  pure  air,  and  any  clothes  that 
interfere  with  the  circulation  should  be  at  once  removed.  If  it 
cannot  swallow,  an  enema  should  be  administered,  so  as  to  clear 
the  bowels  of  any  source  of  irritation  that  may  be  lurking  in 
them.  A  mustard  poultice  may  also  be  applied  to  the  extremi- 
ties. Placing  the  child  at  once  in  a  warm  bath,  so  as  to  excite 
the  cutaneous  circulation  and  relieve  internal  congestion,  is-  a 

*  West,  on  Diseases  of  Infancy  and  Childhood,  1859,  p.  194. 


612  DISEASES    OF    CHILDREN. 

common  and  useful  practice,  whilst  cold  water  is  poured  over  the 
head  and  face  at  the  same  time.  For  the  treataient  of  recurring 
convulsions,  the  late  Sir  James  Simpson  strongly  advocated  the 
use  of  chloroform  inhalations.  Dr.  Wilks  also  speaks  favorably 
of  the  practice.  "In  those  cases  where  the  whole  body  is  con- 
stantly distorted,  to  the  great  distress  of  the  mother,  chloroform 
will  caase  the  movements  instantly  to  cease,  and  sometimes  with 
their  arrest  the  child  may  fall  into  an  apparent  sleep.  I  have 
given  it  in  many  cases  with  the  greatest  advantage  and  relief."* 
It  is  not  necessary  to  keep  the  child  deeply  aupesthetized,  but  just 
to  administer  it  when  each  tit  is  threatening.  When  the  paroxysm 
has  subsided,  the  gums  should  be  lanced  if  tense  ;  and  if  the  pulse 
is  o-ood  and  there  is  sthenic  excitement,  a  scrain  of  calomel  on  the 
back  of  the  tongue  mav  be  needed,  so  as  to  rouse  the  liver  and 
small  intestines  to  freer  action.  In  the  cases  of  strong  and  robust 
children,  where  the  signs  of  active  hypersemia  are  present,  one  or 
two  leeches  may  be  applied  behind  the  ear  or  on  the  temple. 

To  ward  ofi'  a  recurrence  of  the  fits  in  the  intervals,  bromide  of 
» potassium  or  ammonium  will  be  necessary  to  calm  the  nervous 
centres,  and  it  may  be  well  sometimes  to  combirie  with  it  a  few 
grains  of  hydrate  of  chloral  if  there  is  sleeplessness.  Children 
bear  hydrate  of  chloral  well.  "  Given  in  a  dose  sufficient  to  in- 
duce sound  sleep  of  some  hours,  the  convulsions  cease,  and  often 
do  not  recur  when  the  child  wakes.  If  the  child  cannot  swallow, 
five  grains  given  by  the  rectum  soon  induce  a  deep  sleep,  and  the 
convulsions  then  cease,  at  least  temporarily."t 

When  the  convulsions  depend  upon  toxfemic  causes,  as  from  the 
scarlatinal  poison,  the  bowels  must  be  kept  freely  open,  and  elimi- 
nation encouraged.  Above  all,  nitrogenous  food  should  not  be 
indulged  in  where  urtemia  is  dreaded.  If  there  are  worms  in  the 
bowels,  such  remedies  as  aid  their  expulsion  must  be  had  re- 
course to. 

After  the  cessation  of  the  fits,  cod-liver-oil  and  some  prepara- 
tion of  iron,  as  the  syrup  of  the  hypophosphite,  may  be  needed, 
whilst  a  sedative  should  be  given  at  bedtime  to  calm  the  nervous 
system  and  to  promote  sleep. 

Night  Terrors. — A  child  who  suffers  from  this  afiection  generally 
goes  to  bed  quite  well,  and  after  falling  soundly  asleep,  wakes  up 

*  DLsea-ses  of  the  Nervous  System,  1878,  p.  140. 

f  Handbook  of  Therapeutics,  by  S.  Kinger,  M.D.,  8th  edit.,  p.  371. 


INFANTILE   CONVULSIONS   OR   ECLAMPSIA.  613 

in  great  alarm  in  the  coarse  of  an  hour  or  two,  screaming  in  the 
most  terrified  manner.  The  child  fails  to  recognize  the  nurse, 
and  refuses  to  be  appeased.  It  has  probably  been  dreaming  that 
a  cat  is  on  the  bed,  or  that  it  is  pursued  by  a  savage  dog  or  other 
animal,  from  which  i^eannot  escape.  After  a  time  the  nurse  or 
parents  succeed  in  pacifying  the  child  by  petting  it  and  carrying 
it  up  and  down  the  room.  Then  it  falls  off  to  sleep  tranquilly, 
and  wakes  up  as  well  as  usual.  Sometimes  there  is  no  recollec- 
tion whatever  in  the  morning  of  what  had  occurred  during  the 
paroxj'sm  of  terror.  It  is  consolatory  to  parents  to  be  assured  of 
the  harmlessness  of  these  attacks. 

Causes. — These  are  chiefly  indigestion  and  constipation,  but 
diarrhoea  aijd  dentition  are  also  capable  of  exciting  an  attack. 
Worms,  injudicious  feeding,  and  hereditary  syphilis  may  provoke 
it.  Dr.  West  relates  the  case  of  a  boy  who  had  "  night  terrors  " 
for  a  year  before  cutting  his  first  molar  teeth*  Some  seizures 
would  appear  to  be  of  an  epileptic  nature,f  and  others  are  allied  to 
hysteria.^  It  seems  certain  that  weakly  and  nervous  children  are 
most  prone  to  suffer.  These  terrors  are  sometimes  traceable  to 
the  cruelty  of  nurses,  who  frighten  children,  and  create  a  fear  of 
being  in  the  dark.  Overwork  at  school  is  another  cause,  of  which 
the  following  appears  to  be  an  example  :  A  bo}',  12  years  of  age, 
of  anxious  and  nervous  temperament,  was  brought  to  rae  in  1879, 
who,  four  years  previously,  was  seized  with  somnambulism  and 
"night  terrors  ;"  after  being  asleep  for  three-quarters  of  an  hour 
be  would  wake  up  and  get  out  of  bed,  then  walk  out  of  the  room, 
and  if  at  all  interfered  with  would  shriek  and  become  very  violent ; 
when  his  father  and  mother  came  into  the  room  he  knew  them, 
but  seemed  terror-stricken,  and  asked  for  their  protection.  The 
attacks  were  attended  with  cold  hands  and  feet,  clammy  skin,  and 
a  thumping  action  of  the  heart.  When  away  from  home  he  never 
had  any  seizure.  A  year  before  I  saw  him  he  had  several  attacks 
whilst  his  examination  at  school  was  going  on,  and  there  was  some 
evidence  to  show  that  his  brain  had  become  irritable  and  ex- 
hausted. The  urine  contained  phosphates  ;  the  motions  were  large 
and  costive ;  the  abdomen  was  full  and  hard. 

Diagnosis. — These  nocturnal  seizures  make  friends  anxious,  fear- 

*  Diseases  of  Infancy  and  Childhood,  1859,  p.  239. 
t  See  Chap.  XLIII,  p.  588,  On  Epilepsy. 
X  Handfield  Jones,  op.  cit.,  p.  452. 


614  DISEASES   OF   CHILDREN. 

ing  that  some  cerebral  affection  may  be  impending,  but  if  the 
attacks  recur  from  time  to  time,  3^et  each  morning  finds  the  child 
free  from  headache,  and  there  is  no  intolerance  of  light  or  sound, 
no  drowsiness  or  stupor,  and,  moreover,  the  pulse  is  quiet  and 
regular,  and  the  belly  hard  and  of  normal  shape,  then  we  are  cor- 
rect in  attributing  the  symptoms  to  sympathetic  disturbance  in 
the  abdominal  organs. 

Treatinent. — In  the  management  of  this  peculiar  state,  the 
digestive  functions  should  be  carefully  regulated,  and  all  sources  of 
irritation  removed  from  the  intestinal  canal,  by  mild  aperients  of 
soda,  rhubarb,  and  taraxacum  (Form.  19-26),  after  ^vhich,  bromide 
of  potassium  to  allay  nervous  excitement,  and  iron  to  restore  the 
strength,  will  be  required.  The  room  should  have  a  light  in  it, 
and  the  nurse  or  the  mother  be  near  when  the  child  awakes 
frightened.  Mental  discipline  is  most  important.  The  child  re- 
quires to  be  treated  with  kindness,  yet  firmness,  and  if  old  enough, 
reasoned  with  on  the  nature  of  his  ailment.  He  should  be  taught 
not  to  give  way  to  every  impulse,  or  to  become  petulant  on  slight 
provocation. 

3Iental  disorder  is  much  less  frequent  in  children  than  it  is  in 
adults,  still  instances  now  and  then  occur,  and  the  practitioner 
ought  to  be  acquainted  with  the  symptoms  and  the  forms  it  may 
assume.  Cases  are  recorded  in  which  acute  mania  was  set  up  by 
the  exanthemata,  typhoid  fever,  and  cerebral  tumors. 

Melancholia  is  a  state  of  mental  depression  occasionally  met 
with  in  delicate  children  whose  education  has  been  defective,  and 
whose  parents  are  morbid  or  hereditarily  nervous.  Steiner  men- 
tions the  case  of  a  boy,  six  years  of  age,  whose  only  playmate,  his 
sister,  died  of  tubercular  meningitis.  He  grew  melancholy,  lost 
his  appetite  and  sleep,  and  was  tormented  with  the  idea  that  he 
must  die  soon.  This  sad  condition  lasted  two  years,  when  he  re- 
covered.* In  the  adult,  cases  of  mental  shock  are  recorded,  the 
death  of  one  sister  being  soon  followed  by  that  of  the  other ;  and 
the  death  of  one  twin  adult  so  aftected  the  other  that  he  has  suc- 
cumbed to  the  same  disease  in  a  few  weeks.f 

Nervous  and  hysterical  symptoms  in  boys  sometimes  occur,  just 
as  they  do  in  girls  and  young  women,  owing  to  some  unhealthy 
morbid  condition  of  the  nervous  system.     Dr.  Wilks  relates  the 

*  Steiner's  Diseases  of  Children,  by  Lawson  Tait,  1874,  p.  57. 

t  Diseases  of  the  Nervous  System,  by  S.  Wilks,  M.D.,  1878,  p.  398. 


INFANTILE   CONVULSIONS   OR   ECLAMPSIA.  615 

case  of  a  boy  \vho  said  he  was  paralyzed,  and  that  he  could 
neither  see  nor  hear.  When  it  was  proposed  to  apply  a  red-hot 
iron  up  and  down  his  spine,  he  got  up  and  escaped  at  the  door.* 
A  morbid  excitability  of  the  nervous  system  shows  itself  in  at- 
tacks like  croup,  anorexia,  hypersesthesia,  nervous  dyspnoea,  and 
the  like. 

Cretinism  is  a  very  peculiar  disease  allied  to  idiocy.  It  is  an 
epidemic  affection  which  prevails  in  Alpine  districts,  more  espe- 
cially among  the  inhabitants  of  some  parts  of  Switzerland,  the 
Pyrenees,  and  the  Tyrol.  But  it  is  met  with  in  all  quarters  of  the 
globe,  in  the  Himalayas,  Chinese  Tartary,  Madagascar,  the  Rocky 
Mountains  of  l!^orth  America,  and  in  a  small  proportion  of  cases 
in  Derbyshire,  Somersetshire,  and  some  parts  of  Yorkshire.  "  It 
is,  however,  most  common  in  shut-up  valleys,  and  has  a  close  con 
nection  with  goitre.  J^owhere  does  cretinism  occur  where  goitre 
is  absent,  but  goitre  may  occur  where  cretinism  is  unknown  or 
rare."f  It  is  commonly  accompanied  by  an  enormous  goitre,  and 
is  usually  congenital.  Cretins  appear  to  escape  the  ordinary  ail- 
ments of  childhood,  but  they  are  liable  to  diseases  of  the  nervous 
system,  as  convulsions,  hj'drocephalus,  asthma,  and  apoplexy. 
Rickets  ending  in  lameness  is  a  frequent  complication.:!:  The 
cretin  is  so  debased,  and  his  habits  are  so  low  and  disgusting,  that 
he  is  hardly  raised  above  the  animals  that  surround  him.  He  is 
obstinate,  malicious,  and  sensual.  Cretinism  is  a  species  of  idiocy, 
accompanied  by  small  stature,  mostly  under  four  feet,  large  and 
square  head,  vacancy,  and  want  of  expression.  The  sufferer  from 
this  disease  is  sometimes  blind  or  deaf  and  dumb.  Life  may  ex- 
tend to  old  age.  Dr.  Gliggenbuhl,  in  1841,  established  a  hospital 
in  the  Canton  of  Berne,  for  the  purpose  of  educating  these  poor 
creatures ;  and  the  experiment  was  attended  with  some  consider- 
able success. 

Idiocy. — An  idiot  may  be  defined  as  a  person  of  unsound  mind, 
whose  moral  and  intellectual  faculties  are  more  or  less  destroj'ed, 
or  have  never  been  perfectly  developed.  Drs.  Bucknill  and  Tuke 
define  idiocy  as  "  a  congenital  deficiency  of  the  mental  powers."§ 
Dr.  Ireland  gives  the  following  definition :  "  Idiocy  is  mental  de- 
ficiency or  extreme  stupidity,  depending  upon  malnutrition  or 

*  Op.  cit.,  p.  385. 

t  Idiocy  and  Imbecility,  1877,  p.  174.  t  Ibid.,  p.  192. 

^  Psychological  Medicine,  3d  edit.,  1874,  p.  162. 


616  DISEASES   OF   CHILDREX. 

disease  of  the  nervous  centres,  occurring  either  before  birth  or  be- 
fore the  evolution  of  the  mental  faculties  in  chidhood.'"* 

It  may  show  itself  soon  after  birth  as  a  consequence  of  organic 
disease  of  the  brain.  The  affection  is  incurable,  though  sometbing 
may  be  done  in  the  way  of  discipline  and  training.  Some  idiots 
can  scarcely  speak,  whilst  others  articulate  a  few  words,  and  to 
some  extent  are  capable  of  improvement.  Tbey  are  not  able  to 
acquire  knowledge  like  other  children ;  the  mind  remains  childish, 
and  the  countenance  is  void  of  expression  and  intelligence;  the 
forehead  is  low,  the  mouth  open,  the  ears  large,  the  lips  are  thick 
and  everted,  and  the  teeth  are  decayed.  There  is  deafness  and  im- 
perfect articulation,  whilst  the  hands  are  used  awkwardly.  The 
functions  of  organic  and  animal  life  are  more  or  less  impaired, 
nutrition  is  imperfect,  and  the  motions  are  frequently  passed  in- 
voluntarily. Idiocy  may  be  associated  with  stunted  growth,  rick- 
ets, goitre,  etc.  "  • 

The  expression  of  the  idiot  is  good-natured  and  confiding.  Idiocy 
is  frequently  seen  in  the  families  of  those  in  whom  the  neurosal 
tendency  has  been  manifest,  by  such  diseases  as  epilepsy,  insanity, 
and  imbecility.  Dr.  Ireland  says,  "  Idiocy  is  of  all  mental  derange- 
ments the  most  frequently  propagated  by  descent. "f  Of  2000 
cases,  45  per  cent,  presented  well-marked  neuroses  in  one  or  both 
parents.^ 

"  Out  of  420  cases  of  congenital  idiocy  examined,  some  infor- 
mation was  obtained  respecting  the  condition  of  the  progenitors 
of  359.  Now,  in  all  these  359  cases,  save  only  four,  it  is  found 
that  one  or  the  other,  or  both,  of  the  immediate  progenitors  of 
the  unfortunate  sufferers  had,  in  some  way,  widely  departed  from 
the  normal  condition  of  health,  or  violated  the  natural  law.  That 
is  to  say,  one  or  the  other,  or  both  of  them,  were  very  unhealthy 
or  scrofulous;  or  they  were  hereditarily  predisposed  to  affections 
of  the  brain,  causing  insanity ;  or  they  had  intermarried  with 
blood  relatives  ;  or  they  had  been  intemperate,  or  had  been  guilty 
of  sensual  excesses  which  impaired  their  constitutions."§ 

Backwardness. — There  are  some  defective  children  who  cannot 
be  truly  denominated  idiots.     They  are  slow  to  learn ;  "  back- 

*  Idiocy  and  Imbecillity,  1877,  p.  1. 

t  Op.  cit.,  p.  17. 

X  Brit.  Med.  Jour.,  Oct.  11th,  1873. 

2  Report  of  Commissioners  of  Massachusetts  on  the  Causes  of  Idiocy,  1848,  p.  3. 


i:XFA]S'TILE   CONYULSIONS   OR   ECLAMPSIA.  617 

•ward  "  is  the  term  used  here,  "  evfans  arrieres  "  as  the  French  term 
it;  they  cannot  keep  pace  with  other  children  at  school,  at  least 
when  small.  Some  of  them,  however,  brighten  up  considerably 
when  the  pubertal  changes  are  completed,  and  in  ordinary  matters 
can  take  their  part  in  life  fairly  well,  but  they  are  incapable  of 
any  great  mental  eftbrt.  Others  are  not  so  fortunate,  and  con- 
tinue conspicuously  defective  throughout  the  whole  of  life.  Where 
the  parents  possess  sufficient  means,  it  is  well  to  place  these  chil- 
dren under  skilled  supervision,  as  the  training  to  which  they  are 
subjected  is  of  the  most  vital  importance  to  them. 

Imheciliiy  is  a  term  used  to  denote  a  minor  degree  of  mental  de- 
ficiency than  idiocy  (Bucknill  and  Tuke).  Some  imbeciles  know 
those  about  them ;  they  are  affectionate,  and  are  capable  of  tak- 
ing care  of  themselves,  but  passionate  and  inclined  to  theft.  Others 
are  shrewd  and  witty,  jocular  in  their  conversation,  and  cause 
much  amusement.  There  are  those  again  who  are  dangerous  to 
society,  liable  to  commit  acts  of  murder  or  incendiarism. 

"  At  a  very  early  age  the  functions  of  the  brain — at  least  in 
regard  to  its  intellectual  operations — appear  to  have  stopped  ; 
hence  we  see  a  school  full  of  grown-up  boys  and  girls,  sometimes 
of  the  age  of  eighteen  or  twenty,  no  more  capable  of  taking  care 
of  themselves  than  children  of  three  or  four.  They  cannot  use 
their  hands  in  any  ordinary  operation  ;  sometimes  they  do  not 
know  the  way  to  eat  with  a  knife  and  fork,  and  as  a  rule,  the 
newcomers  are  utterly  incapable  of  dressing  or  undressing  them- 
selves. Their  very  actions  are  those  of  little  children;  their 
emotions  and  fears,  their  joys  and  sorrows,  remind  us  most  forci- 
bly of  those  we  witness  in  a  nursery  of  little  ones."* 

Treatment  of  Idiocy  and  Imhecility. — A  great  deal  can  be  done  for 
these  unfortunate  children  in  the  way  of  education.  Institutions 
like  Earlswood  and  K'ormansfield  in  this  country,  and  many  in 
the  United  States,  fully  prove  that  the  treatment  pursued  there 
has  been  attended  with  the  best  results.  The  aim  should  be  to 
put  the  bodily  health  into  the  best  possible  state,  and  then,  by  a 
specially  moral  and  judicious  course  of  teaching,  to  improve  the 
mental  condition. 

Parents  in  the  upper  walks  of  life  are  frequently  disinclined  to 
part  with  children  thus  afflicted,  but  it  will  be  well  to  strongly 
advise  the  placing  of  such  cases  under  proper  training,  as  it  is 

*  Borderlands  of  Insanity,  by  Andrew  Wynter,  M.D.,  1875,  p.  167. 


618  DISEASES   OF    CHILDREN. 

impossible  to  obtain  for  them  at  home  the  same  beneficial  influ- 
ences as  they  would  from  those  who  have  made  the  subject  a 
studj.  Moreover,  it  will  always  be  of  great  importance  to  isolate 
an  idiotic  child  from  the  other  children  of  a  family,  as  the  healthy 
will  ordinarily  tease  and  tyrannize  over  the  weak,  whilst  the  con- 
tact with  imbecility  cannot  be  otherwise  than  detrimental  to  the 
more  fully  developed  minds. 


CHAPTER    XLIY  {contiimed). 

COXGESTIOX    OF    THE    BRAIN. 

Varieties  OF  :  1.  Active  or  arterial.  2.  Passive  or  venous — Congestion  of  the  membranes 
— Hyperemia  of  the  gray  matter.  Causes:  Heart  disease — Vitiated  states  of  the 
blood — Dentition — Injuries  of  the  head — Violent  fts  of  coughing — Prolonged  vomiting. 
Symptoms:  Febrile  disturbance — Heat  of  head — Quick  pulse — Headache — Constipa- 
tion— Sickness — Restless  sleep — Hallucinations  or  delusions  in  some  cases.  Treat- 
ment: Venesection  or  leeching — Purgatives—Starvation — Cold  applications  to  the 
head — Action  of  aconite — Bromide  of  potassium — Hydrate  of  chloral.  Apoplexy 
OR  Cerebral  Haemorrhage  :  Causes — Symptoms — Treatment. 

This  may  be  active  or  arterial,  passive  or  venous ;  active  con- 
gestion being  that  in  which  an  actually  larger  quantity  of  blood 
is  supplied  to  the  brain  and  its  membranes,  and  passive  congestion 
existing  where  there  is  no  increase  in  the  supplj^,  but  an  impedi- 
ment to  the  return  of  the  blood  from  the  brain  and  its  membranes 
to  the  right  side  of  the  heart.  It  occurs  in  so  many  diseases  both 
of  functional  and  organic  origin,  that  it  must  be  viewed  more  as 
a  symptom  than  anything  else.  Still,  I  believe  it  to  be  an  inde- 
pendent affection,  an  uncomplicated  condition,  which  does  occur 
now  and  then  in  infants  and  young  children. 

The  amount  of  cerebral  congestion  varies  a  good  deal  in  differ- 
ent cases.  The  membranes  of  the  brain  are  almost  always  con- 
gested at  the  same  time,  as  the  same  causes  act  upon  both  parts. 
There  is  a  simple  post-mortem  hyperremia,  which  occurs  from 
gravitation  of  the  blood  to  the  lowest  level,  and  is  seen  after 
death  from  febrile  diseases  where  the  blood  remains  unusually 
fluid.  Post-mortem  examination  shows  the  vessels  of  the  brain 
to  be  full  and  enormously  congested  in  some  cases,  where  this  has 
not  been  suspected  during  life.     There  may  have  been  no  stupor, 


CONGESTION   OF   THE   BRAIN.  019 

no  headache,  no  convulsions — no  symptoms,  in  fact,  to  call  atten- 
tion to  this  morbid  state.  When  congestion  is  severe,  not  only 
is  the  brain  more  turgid,  but  its  volume  is  actually  increased. 
The  gray  matter  appears  dark  red  or  violet,  and  where  the  hyper- 
semia  has  been  severe,  as  in  infants  soon  after  birth,  the  white 
matter  may  appear  almost  as  dark  as  the  gray.  On  cutting 
through  the  brain-substance,  drops  of  blood  are  seen  to  ooze  in 
profusion  from  numerous  small  points,  which  are  the  mouths  of 
open  bloodvessels. 

Causes. — Active  congestion  may  occur  in  hypertrophy  of  the 
left  ventricle,  in  connection  with  valvular  disease,  which  is  seen 
in  children  after  rheumatic  fever.  Whatever  excites  the  circula- 
tion propels  more  blood  to  the  brain,  and  overfills  the  vessels  and 
sinuses.  If  it  be  vitiated  by  the  absorption  of  the  scarlatina  or 
small-pox  poison,  we  have  a  most  efficient  cause  of  congestion. 
How  far  again  may  not  cerebral  congestion  be  a  consequence  of 
the  convulsive  paroxysm  rather  than  a  cause,  due  in  part  to 
some  disturbance  of  the  nervous  system,  which  deranges  the  cere- 
bral circulation?  A  child  three  years  of  age,  who  was  in  good 
health,  was  taken  out  in  extremely  cold  weather,  and  when  brought 
home  was  drowsy,  and  the  extremities  were  cold.  It  soon  relapsed 
into  an  unconscious  state  and  died,  death  being  preceded  by  a  con- 
vulsion. No  post-mortem  examination  could  be  obtained,  but  the 
cerebral  symptoms  were  in  all  probability  due  in  great  measure  to 
congestion  of  the  brain  and  its  membranes.  This  pathological 
state,  too,  probably  exists  in  the  preliminary  stage  of  many  dis- 
eases, as  small-pox  and  scarlet  fever.  Congestion  of  the  brain 
occurs  in  the  disturbance  caused  by  dentition,  injuries  of  the  head, 
or  exposure  to  heat,  and  also  in  consequence  of  violent  fits  of 
coughing,  as  in  whooping-cough,  and  from  severe  or  prolonged 
vomiting. 

Symptoms. — The  symptoms  of  cerebral  congestion  are  generally 
those  of  increased  excitability.  There  is  febrile  disturbance,  heat 
of  head,  quick  pulse,  and  disinclination  to  encounter  the  light.  If 
the  child  is  old  enough  it  complains  of  pain  in  the  head,  and  is 
fretful  and  irritable,  any  noise  or  excitement  in  the  room  aggra- 
vating the  symptoms.  Sleep  is  disturbed  by  sudden  starts  and 
muscular  twitchings.  The  bowels  are  generally  constipated,  and 
sickness  and  headache  often  precede  the  outbreak  for  some  days. 
Such  symptoms  as  these  are  common  enough  during  dentition,  and 


620  DISEASES    OF    CHILDREN. 

under  careful  diet  and  suitable  medicines  they  pass  off;  but  when 
they  are  present  we  are  never  certain  what  the  issue  may  be  ;  not 
infrequently  a  fit  of  convulsions  ensues,  consequent  on  the  cerebral 
congestion.  On  the  other  hand,  the  case  may  drag  on,  and  the 
child,  though  recovering  from  the  more  acute  symptoms,  becomes 
listless  and  torpid  ;  it  ceases  to  have  an  interest  in  persons  and 
things ;  it  often  vomits  its  food,  and  the  pulse  is  habitually  quick- 
ened. We  apprehend  the  supervention  of  meningitis,  though  the 
temperature  may  be  scarcely  if  at  all  elevated  till  a  later  stage.* 
The  case  continues,  and  either  a  convulsion  or  drowsiness,  suc- 
ceeded by  heavy  restless  sleep  and  comatose  symptoms,  precedes 
death.  In  other  cases  the  principal  symptoms  are  delusions  or 
hallucinations,  and  the  severest  degree  of  cerebral  congestion  causes 
symptoms  of  apoplexy. 

In  1863  and  1864  I  had  under  my  care  two  children  of  the  same 
family,  aged  respectively  two  and  three  years.  After  being  taken 
out  in  very  cold  weather  they  were  seized  with  symptoms  of  cere- 
bral congestion,  followed  by  drowsiness  and  collapse,  with  coldness 
of  the  extremities.  The  symptoms  were  alarming  for  a  time,  but 
a  warm  bath  and  a  stimulant  in  both  cases  brought  about  recovery. 
The  children  were  both  well  till  the  exposure,  and  they  have  since 
grown  up  strong.  On  the  whole  the  disease  is  not  very  fatal,  but 
repeated  attacks  of  it  lead  to  the  transudation  of  serum  and  oedema 
of  the  brain,  which  may  result  in  imbecility  or  paralysis. 

Treahnent. — This  is  similar  to  that  which  has  been  recommended 
in  simple  meningitis.  In  severe  cases  that  are  seen  early,  where 
the  pulse  is  strong,  leeches  to  the  scalp  may  be  necessary.  Dr. 
"West  records  the  case  of  a  little  girl  two  years  of  age,  who  was 
seized  with  convulsions  and  congestion  of  the  brain  preceding  the 
eruption  of  small-pox.  He  bled  to  three  ounces,  then  applied 
eight  leeches  to  the  head,  and  gave  active  cathartics  without  much 
benefit.  The  restlessness,  squinting,  and  rolling  of  the  head  con- 
tinued, notwithstanding  he  applied  eight  more  leeches  to  the  head, 
which  "  bled  profusely,  and  the  bleeding  was  followed  by  great 
diminution  in  the  convulsive  movements."!  The  eruptive  disease 
ran  its  course  favorably,  and  the  child  recovered.  Bloodletting, 
as  a  rule,  will  not  be  necessary.  It  is  important  to  be  extremely 
cautious  in  the  abstraction  of  blood,  for  young  children  bear  the 

*  See  Chap.  XLII,  pp.  5G4  and  572. 

t  On  the  Diseases  of  Infancy  and  Childhood,  1859,  p.  40. 


CONGESTION   OF   THE   BRAIN.  621 

loss  of  it  badly,  and  we  commit  a  serious  error  if  we  draw  too 
much.  When  the  symptoms  are. relieved  we  should  at  once  arrest 
the  bleeding,  but  if  they  return,  and  the  head  is  hot,  or  there 
is  drowsiness,  convulsion,  or  threatening  coma,  then  we  must  repeat 
the  bleeding;  but  never  unless  the  strength  of  the  child  seems  to 
warrant  it.  A  dose  of  calomel  to  act  as  a  purgative  is  often  ad- 
visable. The  syrup  of  senna,  or  the  sulphate  of  magnesia  and  nitrate 
of  potash  mixture  (Form,  8)  will  be  necessary,  and  if  these  are 
not  eftectual  then  an  active  enema  may  be  needed.  Starvation  or 
little  else  than  cold  water  to  drink,  must  be  enforced.  The  head 
should  be  shaved  and  elevated,  and  cold  applications  applied  and 
cautiously  proceeded  with.  The  ice-cap  is  excellent,  and  where 
this  is  not  at  hand,  pounded  ice,  applied  in  two  bladders,  and 
placed  one  on  either  side  of  the  head,  beliind  the  ears,  will  be  ad- 
visable. The  patient's  room  should  be  dark,  quiet,  and  cool.  If 
the  head  symptoms  are  owing  to  the  exanthemata,  as  soon  as  the 
eruption  of  the  particular  disease  has  appeared  they  usually  sub- 
side ;  and  the  case  from  that  time  pursues  a  favorable  course. 
When  the}^  appear  to  be  the  consequence  of  indigestion,  or  an 
overloaded  state  of  the  stomach,  they  pass  away  as  soon  as  this 
organ  is  once  again  put  in  right  working  order ;  but  the  cause 
must  be  ascertained  lest  we  commit  an  error  in  management. 

In  these  cases,  the  first  point  to  be  attended  to  is  the  tension  of 
the  artery,  which  must  be  our  guide.  If  it  is  full  and  incompres- 
sible then  it  is  clear  that  our  treatment  must  be  directed  towards 
the  lowering  of  this  arterial  tension.  To  dilate  the  arterioles  of 
the  rest  of  the  body  is  one  means  towards  attaining  this  end;  to 
abstract  blood  is  another.  Formerly  the  practice  would  have  been 
to  bleed  the  child,  or  to  apply  leeches,  probably  also  to  purge 
freely.  ]^ow  we  would  prefer  to  deplete  the  congestive  brain  by 
vascular  depressants,  Easori's  plan  of  the  free  administration  of 
tartarated  antimony  held  its  ground  for  many  years,  but  disastrous 
consequences  often  resulted  from  the  free  use  of  it.  TheiL  comes 
the  treatment  of  Fleming,  viz.,  that  of  lowering  the  heart's  action 
and  dilating  the  arterioles  by  the  exhibition  of  aconite.  Aconite 
lowers  the  heart's  action  at  the  same  time  that  it  dilates  the 
arterioles,  and  thus  lowers  arterial  tension — otherwise  the  blood 
pressure  in  the  arteries.*  It  is  well,  also,  to  act  freel}-  on  the 
bowels,  and  therefore  a  purgative  should  be  added  to  the  vascular 

*  See  The  Action  of  Aconite,  Chap.  XI,  p.  128,  and  Chap.  XXXYIII,  p.  460. 


622  DISEASES    OF    CHILDEEX. 

depressant.  This  is  the  more  necessary  as  constipation  is  fre- 
quentl}'  associated  with  the  head  affections  of  children.  Purgation 
ought  to  he  maintained  until  all  the  symptoms  of  congestion  have 
passed  awa3\  Allien  the  congestion  is  accompanied  bv  chronic 
spasms,  heat  of  head,  and  injection  of  the  conjuuctivfe,  then  it  is 
well  to  give  bromide  of  potassium,  or  even  chloral  hydrate. 

Apoplexy^  or  cerebral  hcEinorrhage^  sometimes  occurs  in  infancy 
and  early  life.  Excessive  congestion  of  the  sinuses  of  the  brain, 
and  of  the  vessels  which  ramify  over  its  surface,  takes  place,  and 
this  is  followed  by  rupture.  When  the  brain  is  sliced,  numerous 
small  red  spots  are  seen  in  all  directions,  from  which  blood  oozes, 
and  the  white  substance  has  in  some  cases  a  pale  pinkish  tinge. 
The  haemorrhage  may  take  place  into  the  cavity  of  the  arachnoid 
[meningeal)^  or  the  substance  of  the  brain,  or  very  rarely  into  the 
ventricles  {cerebral). 

This  affection  is  most  common  during  the  first  few  weeks  of  life, 
but  it  ma}^  come  on  during  manj-  diseases,  as  whooping-cough,  con- 
vulsions, and  any  complaint  in  which  there  is  a  strain  thrown  upon 
the  cerebral  vessels,  or  the  blood  is  impeded  in  its  return  from  the 
head,  as  in  congenital  heart  disease,  or  afiections  of  the  bronchial 
glands  pressing  upon  the  large  vessels.  It  is  possible,  too,  that  the 
brain  may  have  sustained  some  injury  during  parturition,  when 
the  head  in  its  slow  transit  through  the  pelvis  has  been  subjected 
to  long-continued  pressure,  the  face  and  the  scalp  attesting  what 
has  taken  place  within  the  skull.  After  a  protracted  confinement, 
or  where  the  mother  has  been  subject  to  puerperal  eclampsia, 
the  child  may  be  born  with  hemiplegia  of  the  face,  arm,  and 
leg,  showing  that  haemorrhage  has  taken  place  into  the  corpus 
striatum. 

The  condition  of  the  cerebral  vessels  in  early  life  is  entirely  dif- 
ferent to  that  of  the  adult ;  the  arteries  being  elastic  and  3'ielding, 
congestion  is  favored,  but  rupture  is  less  likely  to  occur,  because 
their  coats  have  not  undergone  the  degenerative  changes  which 
are  common  in  mature  life.  It  is  true  that  the  coats  of  the  cerebral 
arteries  are  very  thin,  since,  owing  to  the  unyielding  structure  of 
the  cranium  which  encapsules  the  brain,  thej'  are  more  protected 
against  blood  pressure  than  in  softer  parts  of  the  body,  where  tlie 
arteries  can  expand  to  a  greater  extent.  Morbid  conditions,  such 
as  unusual  softening  of  the  substance  of  the  brain,  may  allow  of 
expansion  of  its  thin-'A'alled  arteries  to  a  dangerous  extent.     Fits 


CONGESTION   OF   THE   BRAIN.  623 

of  convulsion,  attacks  of  violent  coughing,  which  produce  enor- 
•mous  fulness  of  the  chief  vessels  of  the  hrain,  rarely  lead  to  rup- 
ture, but  the  smaller  vessels  may  give  way,  and  cause  haemorrhage. 
The  hremorrhage  varies  in  extent.  When  there  are  a  few  dots, 
the  size  of  a  pin's  head,  it  is  termed  capillary  haemorrhage. 

The  ST/rnjytoms  which  denote  this  condition  vary  according  to 
the  suddenness  or  gradual  approach  of  the  seizure.  It  would  he 
impossible  to  enumerate  conclusive  symptoms.  When  sudden, 
there  are  stupor  and  convulsions.  "  The  sudden  occurrence  of 
violent  convulsions,  and  their  frequent  return,  alternating  with 
spasmodic  contraction  of  the  lingers  and  toes  in  the  intervals, 
appear  to  be  the  most  frequent  indications  of  the  effusion  of  blood 
upon  the  surface  of  the  brain."* 

When  an  extravasation  is  small,  the  s^miptoms  may  be  obscure 
or  even  absent ;  but  when  large,  and  it  occurs  in  the  substance  of 
the  brain,  or  in  the  cavity  of  the  arachnoid,  the  usual  symptoms 
of  compression  may  be  looked  for.  The  child  lies  in  an  uncon- 
scious state,  wnth  a  dusky  face  and  contracted  pupils,  the  eyes  are 
dim,  the  pulse  small  and  slow,  the  respiration  is  irregular  and 
usually  slow  and  superficial.  Vomiting  is  often  present,  and  the 
bowels  may  be  constipated  or  loose.  A  severe  attack  of  cerebral 
haemorrhage  is  always  accompanied  with  involuntary  evacuation 
of  the  urine  and  faeces.  If  the  child  is  fed  at  the  breast,  it  loses 
its  hold  of  the  nipple,  and  cannot  retain  it  in  the  mouth.  In 
larger  effusions  in  older  children,  the  attack  is  usually  sudden ; 
headache,  restlessness,  and  disturbed  sleep,  unconsciousness,  loss 
of  speech,  convulsions,  and  irregular  breathing,  may  be  the  pre- 
cursors of  death.  In  the  commencement  of  the  attack,  the  tem- 
perature generally  falls  to  96°  or  95'-\  from  irritation  of  the 
controlling  centres  of  heat  production  ;  while  later  on,  more  es- 
pecially when  the  blood  breaks  into  the  lateral  ventricles,  the 
temperature  begins  to  rise.  Where  this  rise  is  sudden  and  exten- 
sive, as  when  the  mercury  runs  up  to  103°  or  105°  in  a  few  hours, 
it  is  a  sure  sign  of  impending  collapse  and  death. 

Treatment. — When  the  case  is  seen  early,  leeches  to  the  head 
have  been  recommended,  but,  as  a  rule,  this  will  be  rarely  neces- 
sary, a  dose  of  calomel  and  purgative  enemata  being  usually  active 
enough  for  a  child.     Under  this  mode  of  treatment  the  symptoms 

*  West,  On  the  Diseases  of  Infancy  and  Childhood,  1859,  p.  61. 


624:  DISEA>SES    OF    CHLLDREX. 

may  disappear.    The  head  should  be  shaved  and  cold  applied.     If 
the  gums  are  distended  thej  should  be  lanced. 


CHAPTER    XLY. 

CHOREA     OE     ST.    VITUS'S     DAXCE. 

Defixitio:5v  axd  Symptoms  :  Sometimes  b''gins  insidiously,  or  v:ifh  convulsive  movements 
of  face — Difficulty  of  speech,  and  deglutition — Inability  to  stand  or  walk — Shuffling  move- 
ments as  if  paralyzed — Quietude  during  sleep  a^  a  rule — Disorder  of  digestive  organs — 
Foul  breath — Constipation — Hemichorea — General  chorea — Cardiac  murmurs — Palpi- 
tathn — State  of  the  urine.  CArSES :  General  debility,  ancemia,  worms  in  the  intestinal 
canal — Irritability  of  the  nervous  system — Female  sex  most  liable — Fright,  anger,  blows, 
or  injury — A  sequence  or  association  with  rheumatism — Masturbation,  its  association 
with  epilepsy — An  occasional  conseguence  of  the  eruptive  fevers.  Pathology  :  Theory 
of  embolism — Hyperosmia  of  the  nerves  centres — Thickening  and  vegetations  of  mitred 
valve — Congestion  and  hcemorrhage  of  corpora  striata  and  thalami  optici — Congestion  of 
spinal  cord.  Treatment  :  Best  in  bed —  Utility  of  purgatives — Conium — Hypodermic 
injection  of  curara — Hyoscyamia — Hydrate  of  chloral — Iron — Bromide  of  potassium — 
Arsenic — Strychnia — Sulphate  of  zinc — Phosphorus — Hypophosphite  of  soda — Cod-liver 
oil — Quinine  and  bark — Tartarated  antimony — Sea^air — Shower-baths — Galvanization 
— Faradization. 

Chorea  may  be  accepted  as  one  of  the  most  singular  of  the 
numerous  disorders  which  aifect  the  nervous  system.  It  is  sub- 
stantially allied  in  some  respects  to  other  neurosal  conditions  ;  but 
it  is  so  variable  and  capricious  in  its  manifestations  that  it  may 
be  clinically  recognized  as  possessing  peculiar  and  independent 
phenomena,  which  distinguish  it  from  all  other  aftections. 

Chorea  is  a  functional  derangement  of  the  motor  nerves,  caus- 
ing irregular  movements  of  the  muscles,  and  influencing  voluntary 
action.  It  is  a  common  disorder  in  nervous  and  sensitive  children, 
from  the  greater  excitability  of  the  nerve-cells  in  youth.  It  is 
not  accompanied  by  fever.  With  it  there  is  no  defect  of  conscious- 
ness or  volition,  as  is  the  case  with  epilepsy. 

Symptoms. — The  disease  occasionally  creeps  on  slowly  and  insid- 
iously, the  child  being  out  of  health  for  some  time  before  any 
choreic  movement  is  observed.  The  first  sj^mptoms  are  restless- 
ness and  inability  to  sit  still  for  even  a  short  time,  and  the  parents 
not  unnaturally  ascribe  this  to  a  fidgety  habit,  which  may  and 
ought  to  be  controlled  by  discipline.  In  other  cases  the  disease 
begins  with   a  slight  twitching  of  the  muscles  of  the  face,  the 


CHOREA   OR   ST.  VITUS's   DANCE.  625 

patient  putting  the  mouth  into  the  most  grotesque  forms  and 
contortions,  as  if  mocking  or  "  making  mouths  "  at  you.  In  other 
instances  the  facial  muscles  escape  and  the  tremulous  agitation  is 
confined  to  the  limbs.  When  asked  to  put  out  the  tongue  it  is 
accomplished  suddenly,  or  with  a  peculiar  rolling  motion,  and 
then  withdrawn  in  like  manner;  but  it  is  sometimes  protruded 
with  ease,  and  kept  out  for  a  short  time.  Eating  and  swallowing 
are  performed  with  difficulty,  and  the  food  drops  from  the  mouth 
because  there  is  no  control  over  the  tongue  and  pharyngeal 
muscles.  The  speech  is  often  thick  and  hesitating,  and  the  child 
twists  and  turns  its  mouth  and  head  in  the  endeavor  to  get  out  a 
sentence.  There  is  a  general  unwillingness  to  utter  a  w^ord,  and 
the  tongue  is  sometimes  bitten  in  the  attempt  to  speak.  After  a 
time  the  disease  extends  to  one  or  both  arms,  and  later  on  to  the 
legs,  and  thus  all  the  voluntary  muscles  become  implicated  in 
spasmodic  action.  The  child,  if  a  female,  will  perpetually  pluck  at 
her  dress,  raise  her  hand  to  her  head  as  if  to  play  with  her  hair, 
or  rapidly  put  it  behind  her;  she  will  be  noticed  at  this  stage  to 
drop  things  out  of  her  hand,  and  to  be  unable  to  hold  or  direct 
her  pencil  when  at  school.  In  walking  she  leans  on  one  side, 
drags  one  leg,  or  raises  it  awkwardly.  Her  walk  is  a  jumping, 
unsteady-,  sudden,  shufiling  kind  of  gait,  as  though  the  joints 
hung  loosely,  and  she  was  compelled  to  put  herself  together 
before  making  the  attempt.  The  manner  of  locomotion  is  ludi- 
crous and  fantastic  in  the  extreme,  the  writhing  of  the  shoulders, 
the  careless  semi-drunken  sway,  and  the  peculiar  grimace,  or 
fatuitous  expression  of  the  features,  are  all  characteristic.  The 
movements  cease  with  sleep  and  the  abolition  of  consciousness. 

In  severe  cases  the  patient  is  unable  to  stand  or  walk.  If  she 
can  manage  to  walk,  she  shuffles  along  in  a  nervous  hesitating 
manner,  as  if  afraid  of  falling  down  every  moment.  The  knees 
and  elbows  may  be  polished  from  friction,  and  even  the  skin 
abraded ;  the  chin  is  red,  and  the  lips  sometimes  bleed  from  biting 
and  friction  against  the  pillow.  So  violent  are  the  paroxysms 
that  the  back  may  be  arched  one  moment,  and  stiff  and  straight- 
ened the  next.  The  speech  may  be  unintelligible,  and  the  emaci- 
ation become  extreme  if  the  case  goes  on.  The  pulse  is  not  accel- 
erated except  from  debility  and  nervous  agitation.  In  some  cases 
it  is  slow,  and  may  not  exceed  sixty  beats  a  minute  in  a  child 
thirteen  years  of  age.     Irregularity  and  intermission  of  the  pulse 

40 


626  DISEASES   OF   CHILDEEN. 

are  often  present.*  The  tongue  is  sometimes  furred,  the  breath 
foul,  and  the  bowels  constipated.  The  patient  is  liable  to  great 
variation  in  the  progress  of  the  malady,  being  sometimes  better 
and  sometimes  worse.  When  the  attacks  are  threatening  there 
may  be  mental  irritability,  and  evidence  of  spitefulness.  In  one 
case  that  came  under  my  notice  a  child,  whose  intellect  was  below 
the  average,  was  unable  to  restrain  herself  from  kicking  and 
biting  those  about  her.  In  chronic  cases,  parents  can  often  judge 
when  an  attack  is  threatening,  or  when  the  case  is  becoming 
worse,  from  the  altered  manner  and  disposition  of  the  child. 
Timidit}',  caprice,  and  wilfulness  are  noticeable  when  the  intellec- 
tual faculties  are  disordered,  and  it  is  in  such  cases  as  these  that 
we  ma}'-  see  fits  of  passion  pass  into  temporary  unconsciousness. 
I  have  known  the  symptoms  much  aggravated  by  another  patient 
in  the  same  ward  practicing  these  extraordinary  movements  and 
mimicries,  or  suffering  from  a  painful  disease  which  has  irritated 
the  chikl.  This  is  the  only  explanation  I  can  furnish  of  a  choreic 
child's  temperature  going  up  to  102'^  for  three  nights,  and  falling 
next  day  to  normal  when  removed  into  another  ward.  Sir  T. 
Watson  mentions  in  his  lectures  that  "  chorea  is  liable  to  be  propa- 
gated hj  a  species  of  contagion,  or  rather  involuntary  imitation. "f 

Sometimes  the  loss  of  power  of  co-ordination  is  so  great  that 
the  patient  cannot  pick  up  an  object  with  the  fingers,  or  even 
grasp  anything  with  the  hand. 

In  one  case  under  my  care  the  choreic  movements  were  pre- 
ceded by  headache  of  three  months'  duration — a  disorder  which 
had  not  previously  been  experienced.  The  patient  was  a  girl  ten 
years  of  age,  who  had  become  very  anxious  about  her  studies. 
This  symptom  of  headache,  according  to  my  experience,  is  exceed- 
ingly rare,  except  as  the  accompaniment  of  anferaia  and  debility. 
Sir  T.  Watson  has  frequently  met  with  instances  of  pain  in  the 
head  in  chorea;  "and  in  some  of  them,  with  pain  on  that  side 
onli/  of  the  head  which  was  opposite  the  agitated  limbs. "|" 

Chorea  is  very  prone  to  recur,  and  a  child  who  has  had  one 
attack  is  always  exposed  to  a  return  at  some  future  period. 

*  See  a  paper  by  the  autlior,  On  Neurosal  Affections  of  the  Heart  in  Children, 
Practitioner,  Sept.,  1878. 

t  Princii)les  and  Practice  of  Physic,  4th  edit.,  vol.  i,  p.  668. 
X  Op.  cit.,  vol.  i,  p.  673. 


CHOREA   OR   ST.  VITUS's   DANCE.  627 

When  the  spasmodic  movements  are  unilateral,  afi'ecting  the 
limbs  of  the  same  side,  the  patient  is  said  to  have  "  hemichorea." 
When  this  happens,  the  right  side  is  oftener  affected  than  the  left. 
Both  legs  may  be  affected  and'  only  one  arm ;  or  one  arm  alone, 
whilst  the  legs  are  free.  In  rare  cases,  one  arm  and  the  leg  of  the 
opposite  side  of  the  body  may  be  involved.  When  all  the  volun- 
tary muscles  are  implicated  there  is  '■'general  chorea.'''' 

Cardiac  murmurs  are  sometimes  present  in  this  affection,  and  in 
the  early  stages  of  the  disorder  they  are  often  overlooked.  In 
some  cases  we  may  find  exaggerated  action  and  impulse  of  the 
heart,  or  a  bellows  murmur  at  the  left  apex,  with  other  accom- 
paniments of  mitral  regurgitation.  When  the  heart  is  so  affected 
it  is  often  traceable  to  rheumatism.  In  other  cases  the  heart  is 
healthy,  but  the  neurotic  disorder  has  implicated  the  cardiac 
plexus,  and  produced  irregularity  in  frequency,  and  deficiency  of 
power ;  or  there  are  to  be  discovered  merely  the  evidences  of  pal- 
pitation, with  prolongation  of  the  first  sound  both  at  apex  and 
base — a  soft  systolic  murmur,  in  fact,  which,  though  often  signifi- 
cant of  organic  change,  may  happen  in  some  examples  of  simple 
ansemia  and  general  debility. 

Sometimes  palpitation  is  very  severe  and  violent,  and  there  may 
be  a  systolic  mitral  murmur  of  dynamic  origin,  which  passes  away 
with  the  seizure  as  the  general  health  is  restored. 

The  urine  is  often  found  to  be  of  high  specific  gravity,  exces- 
sively acid,  turbid,  and  containing  an  excess  of  urea,  and  some- 
times phosphates.  In  the  twelve  cases  I  have  alluded  to  below, 
the  highest  specific  gravity  was  1032  ;  there  was  a  copious  deposit 
of  whitish  lithates  in  three,  phosphates  in  four,  and  in  the  remain- 
ing five  (which  were  mild  cases)  the  urine  was  normal.*  In  one 
case  under  my  care  the  urine  contained  copious  phosphates  for  five 

*  In  twelve  consecutive  cases  admitted  under  my  care  into  the  Samaritan  Hospital, 
ten  were  females ;  the  eldest,  a  girl,  was  fourteen  years  of  age,  and  the  youngest  a  boy 
of  seven.  Four  cases  were  traced  to  fright,  two  followed  measles,  one  arose  from  bad 
living  and  deficient  food,  one  occurred  in  a  cachectic  and  strumous  child,  two  came  on 
gradually  from  general  debility,  one  from  school  work  and  punishment,  and  one  case 
occurred  suddenly,  the  child  failing  down  in  the  street  in  a  species  of  fit,  followed  by 
general  chorea.  In  this  case  there  was  a  loud  systolic  murmur  of  long  standing,  not 
traceable  to  rheumatism.  In  six  cases  the  left  side  was  attacked,  in  three  the  right, 
and  in  the  remaining  three  the  movements  were  not  more  on  one  side  of  the  body  than 
on  the  other. 

"  Among  eleven  chorea  patients  which  I  noted  in  my  diary,  I  find  only  one  boy 
affeeted." — Vogel,  Diseases  of  Children,  1874,  p.  398. 


628  DISEASES   OF  CHILDRElSr. 

days  in  succession,  and  the  specific  gravity  was  never  below  1030. 
During  this  time  the  child  was  takinor  from  eisrhteen  grains  to  one 
drachm  of  sulphate  of  zinc  in  the  twenty-four  hours.  When  she 
took  eighty  grains  in  the  day,  the  urine  suddenly  became  loaded 
with  lithates,  and  the  day  following,  when  the  zinc  was  reduced, 
it  was  normal. 

Causes. — AgQ  has  a  great  influence  on  the  production  of  chorea. 
Two-thirds  of  all  cases  occur  between  the  second  dentition  and 
the  development  of  puberty,  between  five  and  fifteen  years  of 
age.  The  influence  of  sex  is  also  considerable,  as  girls  sufter  from 
it  more  than  boys,  the  proportion  being  about  three  girls  to  one 
boy. 

Among  the  causes  of  this  afi:ection  are  to  be  reckoned  defective 
nutrition,  general  debility,  and  anfemia,  worms  in  the  intestinal 
canal,  and  disorder  of  the  digestive  organs.  In  fact,  any  circum- 
stances which  tend  to  lower  the  standard  of  health  in  debilitated 
subjects,  such  as  bad  air  and  food,  are  likely  to  generate  the  disease 
in  children  of  delicate  nervous  organization.  These  causes  most 
probably  account  for  the  great  frequency  of  chorea  among  persons 
engaged  in  pottery  manufacture,  as  stated  by  Dr.  Arlidge.*  Irri- 
tability of  the  nervous  system  is  among  the  most  frequent  causes, 
and  hence  this  is  assigned  as  one  reason  of  its  frequency  in  the 
female    sex.f      Overanxiety   in    school-work    is    another   cause. 

•*  The  Pathology  of  Chorea,  Brit.  Med.  Journ.,  1877,  vol.  ii,  p.  799. 

f  "  But  though  the  fact  of  the  greater  liability  of  tlie  one  sex  to  chorea  is  undoubted, 
so  that  of  775  children  suffering  from  it  who  were  admitted  as  in  or  out-patients  of  the 
Children's  Hospital,  499,  or  64  per  cent.,  were  girls ;  still,  not  only  were  all  of  these 
children  under  the  age  of  ten,  but  66  out  of  102  of  the  number  were  under  the  age  of 
five."— On  Some  Disorders  of  the  Nervous  System  in  Childhood,  by  C.  West,  M.D., 
F.K.C.P.,  1871,  p.  47. 

"  Of  422  cases  occurring  up  to  twelve  years  of  age,  122  were  males,  and  300  females. 
Between  the  ages  of  four  and  five  the  proportion  of  males  to  females  was  as  4  to  16,  and 
between  ten  and  twelve,  as  23  to  81.  Again,  when  chorea  occurred  after  puberty,  it 
was  among  women  that  it  was  principally  seen ;  yet  as  chorea  was  not  confined  exclu- 
sively to  females,  we  must  seek  the  cause  in  a  factor  common  to  both,  but  especially 
intense  or  prominent  in  the  female." — Croonian  Lectures,  by  J.  Braxton  Hicks,  M.D., 
F.RS.,  1877. 

"Up  to  nine  years  of  age  the  two  sexes  appear  to  be  equally  liable;  after  this  age 
females  become  much  more  liable  than  males,  in  the  proportion  of  nearly  5  to  2." — 
Chorea,  by  C.  H.  C.  Radcliffe,  M.D.,  Reynolds's  vSystem  of  Medicine,  vol.  ii,  2d  edit., 
p.  188. 

"The  'chorea  of  childhood'  has  come  largely  under  my  notice  at  the  Stafford  County 
Infirmary,  and  drawing  my  conclusions  from  cases  seen  at  tliat  institution,  I  am  dis- 


CHOREA   OR   ST.  VITUS's   DANCE.  629 

Nervous  disease  in  the  family  especially  predisposes  to  it.  Hys- 
teria in  the  mother,  or  epilepsy  in  the  father ;  melancholy,  suicide, 
or  insanity  in  the  parents,  can  be  frequently  traced. 

Fright,  anger,  and  injury  may  also  induce  chorea.  Several 
cases  have  come  before  me  in  which  the  disease  has  been  traceable 
to  terror  and  alarm.  One  of  the  worst  cases  Lever  saw  came  on 
suddenly  in  a  girl,  10  years  of  age,  from  seeing  a  dead  person. 
In  another  case  which  came  under  my  notice  in  February,  1879, 
a  girl,  eight  years  of  age,  had  three  severe  seizures :  the  first 
from  grief  at  the  death  of  a  sister  ;  the  second  from  seeing  a  lady 
killed  in  the  street ;  and  the  third  from  hearing  of  the  sudden 
death  of  her  grandfather.  Chorea  sometimes  arises  during  con- 
valescence  from  acute  rheumatism  ;  it  is  seen  in  secondary  syph- 
ilis and  other  toxic  changes  in  the  blood.  It  may  result  from 
embolism  in  connection  with  rheumatic  endocarditis,  but  the  con- 
currence of  chorea  with  rheumatic  fever  is  not  quite  so  frequent 
as  is  supposed,  though  it  cannot  be  denied  that  the  rheumatic 
constitution  is  sometimes  associated  with  it.*  In  the  twelve 
cases  referred  to  there  was  no  history  of  rheumatic  fever  in  any 
of  them,  and  in  a  large  number  of  cases  I  have  failed  to  discover 
anything  more  than  a  casual  relationship. 

Of  66  cases  of  chorea  observed  by  Dr.  West,  16  were  accom- 
panied or  preceded  by  rheumatic  symptoms,  and  in  11  of  these 
there  was  a  systolic  bruit  persisting  after  convalescence  in  10.  In 
one  of  the  16  cases,  rheumatic  symptoms  and  heart  disease /o^/oi/;e(^ 
in  the  course  of  the  chorea ;  in  all  the  other  cases  the  rheumatism 
preceded  it.  In  9  cases,  although  there  w^as  no  rheumatism  pres- 
ent, nor  any  history  of  rheumatism,  the  heart  was  the  seat  of 
valvular  affection  when  the  patients  came  under  observation. f 

A  case  of  chorea  is  related  by  Dr.  Althaus,  where  it  came  on 
from  masturbation  at  fifteen  years  of  age,  and  after  lasting  for  six 
years,  it  became  complicated  with  epilepsy.  Arsenic,  bromide  of 
potassium,  and  various  nerve  tonics  and  sedatives  failed.    Hydrate 

posed  to  fix  the  age  at  which  it  is  most  frequently  met  with  as  being  between  siz  and 
eleven  years,  the  generality  of  cases  occurring  somewhere  midway  between  these  ages." 
—  On  Certain  Convulsive  Disorders,  by  H.  Day,  M.D.,  F.E.C.P.,  Medical  Society's  Pro- 
ceedings, vol.  iv,  p.  85. 

*  "  Chorea  is  apt  to  supervene  in  young  subjects  after  the  cessation  of  the  febrile 
disturbance  in  rheumatic  fever  where  the  heart  has  been  implicated." — Rheumatism, 
by  A.  B.  Garrod,  M.D.,  F.R.S.,  Keynolds's  System  of  Medicine,  1876,  vol.  i,  p.  931. 

f  West,  op.  cit.,  p.  52. 


630  DISEASES   OF   CHILDEEX. 

of  chloral  checked  the  restlessness  and  general  convulsion  till  the 
patient  got  into  the  habit  of  taking  immoderate  doses,  and  at  last 
died  in  1874.* 

We  may  sometimes  witness  chorea  in  children  who  have  been 
badly  fed,  and  who  have  had  their  health  reduced  by  scarlet  fever 
and  measles,  and  whose  parents  are  nervous  and  consumptive.  In 
a  case  under  my  care  in  1875,  with  such  a  history,  two  children 
out  of  a  family  of  four  died  of  convulsions.  In  a  family  with 
whom  I  was  once  acquainted,  one  daughter  had  severe  chorea,  the 
other  died  of  convulsions,  a  son  perished  tVom  phthisis,  the  father 
hanged  himself,  and  the  mother  died  of  parah'sis. 

(Chorea  presents  some  points  of  difference  when  it  occurs  in  old 
people.  The  disease  in  them  appears  to  be  remarkably  rare,  but 
to  be  incurable.  The  movements  of  the  face  and  limbs  are  not  so 
active,  and  the  disease  is  more  chronic.  According  to  Charcot, 
chorea  in  old  people  is  an  emotional  disease,  and  is  unaccompanied 
by  any  cardiac  lesion.  The  subject  of  it  often  labors  under  more 
or  less  dementia,  and  it  has  no  connection  with  rheumatism,  like 
chorea  in  early  life.)f 

Pathology. — There  are  two  theories  extant,  one  in  which  the 
disease  is  attributable  to  embolism,  and  the  other  to  hyperfemia. 
Both  have  found  able  advocates.  Dr.  Dickinson  is  opposed  to  the 
embolic  theory,  and  it  appears  to  me  inconsistent  with  the  history 
and  clinical  features  of  the  disorder.  Of  seven  fatal  cases  in  which 
Dr.  Dickinson  made  post-mortem  examinations,  he  found  no  plug 
of  fibrin  in  any  of  the  arteries.  Of  twenty-two  fatal  cases  which 
he  examined,  the  frequency  of  mitral  endocarditis  was  notice- 
able.:}; He  believes  the  disease  to  consist  in  hypertemia  of  the 
nervous  centres,  particularly  of  the  corpora  striata  and  thalami 
optici,  and  that  congestion  in  the  cervical,  dorsal,  and  lumbar 
portions  of  the  spinal  cord  is  frequently  to  be  detected.  Dr. 
Broadbent  has  seen  "  one  fatal  case  of  rheumatic  chorea  with  de- 
lirium, in  which  there  was  plugging  of  minute  vessels  of  the  brain 
with  decolorized  clots. "^  Dr.  Hughliugs  Jackson  has  met  with 
emboli  in  the  small  arteries,  and  others  have  seen  them  in  the 
corpora  striata.||     The  slow  manner  in  which  the  disease  so  fre- 

*  Clin.  Trans.,  vol.  xi,  p.  62. 

t  On  Chorea  in  Old  People,  by  Prof.  Charcot,  Med.  Times  and  Gazette,  March  9th, 
1878,  p.  245. 

X  On  the  Pathology  of  Chorea,  Med.-Chir.  Trans.,  1875. 

I  Lancet,  Oct.  16th,  1875,  p.  560.  ||  Ibid. 


CHOEEA   OR   ST.  VITUS's   DANCE.  631 

queiitly  creeps  on,  and  returns  from  time  to  time  at  uncertain 
intervals,  the  occasional  sudden  disappearance  of  the  disorder,  and 
the  seizures  being  often  general  instead  of  onesided,  are  not  con- 
sistent with  the  theory  of  embolism.  Dr.  Handfield  Jones  truly 
observes,  "  that  there  seems  no  more  reason  for  requiring  a  demon- 
strable lesion  in  chorea  than  in  many  cases  of  insanity  or  delirium 
tremens,  between  which  and  chorea  a  considerable  analogy  cer- 
tainly exists.^' 

In  two  cases  of  "  canine  chorea  "  there  was  found  after  death, 
in  one  case,  a  granular  and  swollen  condition  of  the  nerve-cells  of 
the  spinal  cord,  and  in  the  second  case  there  was  seen,  in  addition, 
a  similar  lesion  in  the  medulla  oblongata  and  cerebellum,  while 
the  corpora  striata  and  hemispheres  were  free  from  it.f 

When  the  chorea  is  associated  with  temporary  loss  of  conscious- 
ness and  with  convulsive  seizures  (hysterical  or  epileptoid).  Dr. 
Gowers  thinks  the  disease  may  depend  on  an  unstable  condition 
of  the  nerve-centres,  or  on  imperfect  development  or  nutrition  of 
these  centres.  He  mentions  several  cases  illustrating  the  associa- 
tion of  chorea  with  epilepsy,:]:        « 

In  some  fatal  cases,  evidences  of  inflammatory  lesion  have  been 
found  in  the  lungs,  pleura,  brain,  peritoneum,  and  spinal  cord 
(myelitis),  and  there  have  been  also  noticed  hypersemic  patches  of 
extravasation  in  the  coats  of  the  aorta  and  endocardium,  when 
these  did  not  depend  on  rheumatism.  The  chorea  probably  pos- 
sesses the  tendency  to  so  atfect  the  nervous  centres  as  to  destroy 
the  balance  that  normally  exists  between  them  and  their  vascular 
supply.  Perhaps  the  most  frequent  change  is  that  of  "  vegeta- 
tions," or  fibrinous  deposit  on  the  valves  of  the  heart.  In  34  fatal 
cases,  18  presented  these  alterations,  and  there  was  scarcely  one  of 
them  in  which  the  changes  could  be  traced  to  embolism  (Handfield 
Jones). 

Treatment. — Rest  in  bed  is  the  first  and  most  important  step  to 
observe,  and  with  rest  alone  there  is  no  doubt  that  many  cases 
recover.  Drugs  exert  only  a  secondary  influence.  Where  the 
convulsive  movements  are  incessant,  splints  softly  padded  should 
be  applied  to  the  limbs,  and  it  may  be  even  necessary  to  cover  the 

*  On  Functional  Nervous  Disorders,  1870,  p.  355. 

+  Tiie  Pathological  Anatomy  of  Canine  Chorea,  by  W.  R.  Gowers,  M.D.,  and  H.  R. 
O.  Sankey,  M.R.C.S.,  Med.-Chir.  Trans.,  1877,  p.  229. 
X  Brit.  Med.  Journ.,  April  6th,  1878,  p.  481. 


632  DISEASES    OF   CHILDREN. 

body  with  cotton-wool  to  prevent  the  patient  from  sustaining 
bruises  and  excoriations.  It  is  then  advisable  to  remove  any  ec- 
centric source  of  irritation  wherever  it  may  exist.  If  there  is 
feculent  matter  in  the  bowels,  and  constipation,  as  frequently  hap- 
pens, raild  purgatives,  such  as  rhubarb  and  castor  oil,  are  to  be 
selected.  In  some  cases  where  the  muscular  agitation  is  great, 
free  purging  will  be  followed  by  rapid  improvement,  and  this  pre- 
liminary treatment  ought  never  to  be  omitted  if  there  is  any 
reason  to  suppose  that  the  intestinal  tract  is  disordered.  Un- 
healthy motions,  scanty  and  high-colored  urine,  demand  this  treat- 
ment.* A  case  of  acute  chorea  in  a  girl  of  nine,  which  had  lasted 
a  month,  is  referred  to  by  Dr.  Handiield  Jones.  The  attack  was 
very  aggravated.  The  movements  w^ere  incessant,  and  there  were 
sordes  on  the  lips,  a  bedsore,  rapid  feeble  pulse,  and  a  tendency  to 
sinking.  After  a  dose  of  male  fern,  a  tapeworm  seven  yards  long 
came  awa}^,  and  in  a  few  days  the  convulsive  movements  ceased 
and  the  child  recovered  completely. f 

To  relieve  the  dryness  of  the  skin,  which  is  frequent  in  chorea, 
and  to  produce  moisture,  a  war^ii  bath  at  bedtime  should  be  em- 
ployed, and  this  has  been  recommended  and  adopted  both  by 
English  and  Continental  physicians.  Sulphur  baths  have  been 
highly  spoken  of  by  French  w^riters. 

Succas  conii  has  been  recommended,  but  my  experience  does  not 
enable  me  to  speak  in  its  favor.  We  do  hear  of  and  see  cases 
w^here  two  drachms  have  produced  certain  physiological  effects,  as 
dimness  of  vision  and  dilatation  of  the  pupil,  but  I  have  given 
sixteen  drachms  in  the  space  of  twenty-four  hours  without  pro- 
ducing anj'  sedative  effects  whatever ;  indeed,  in  the  case  to  which 
I  refer,  of  chronic  chorea,  the  child,  aged  ten  years,  w^as  no  more 
affected  than  if  she  had  taken  water  only.  Dr.  West  gives  similar 
evidence  regarding  the  use  of  this  drug,  and  also  of  henbai^e  and 
belladonna.  He  has  known  them  to  be  tolerated  in  poisonous 
doses  without  any  result  for  good  or  evil.:}:  Curara  is  another 
remedy.  § 

*  Formula  84 : 

Be.  Potass,  sulphat., gr.  x 

Pulv.  rhei,  .........     gr.  iv. — M. 

To  he  taken  in  the  early  morning.     For  a  child  ten  years  of  age. 
t  On  Functional  Nervous  Disorders,  1871,  p.  355.  J  Op.  cit.,  2^  72. 

§  Dr.  Drummond,  of  Xewcastle-on-Tyne,  succeeded  in  curing  an  obstinate  case  of 
general  chorea  in  a  girl  seven  years  of  age,  by  the  subcutaneous  injection  of  curara. 


CHOREA    OR   ST.  VITUS'fi   DANCE.  G33 

Dr.  Pulmont  found  that  gr.  '  of  hyoscjamia  augmented  to  gr. 
J  twice  a  day,  proved  very  efficacious  in  chronic  cases  in  aduUs, 
the  improvement  usually  setting  in  in  the  course  of  eight  or  nine 
days.  Symptoms  of  intoxication  were  occasionally  observed,  in- 
dicated by  dryness  of  the  mouth  and  dilatation  of  pupils.* 

Chloral  hydrate  has  been  recommended  in  large  doses  in  violent 
chorea. f  The  principle  of  treatment  w^as  to  give  thirty  grains, 
and  to  repeat  the  dose,  or  half  of  it,  if  the  patient  did  not  obtain 
ten  hours'  sound  sleep  in  the  twenty-four  hours.  On  waking,  a 
second  dose  was  given  in  proportion  to  the  ascertained  efl'ect,  but 
always  less  than  the  first.     On  waking  again  another  dose  less 

He  commenced  with  an  aqueous  solution  of  gr.  ^^^  for  two  days,  increasing  tlie  dose  on 
the  third  day  to  gr.  ^^j,  and  the  next  day  to  gr.  -j'^,  on  the  fifth  day  to  gr.  ^,  and  on  the 
sixth  day  to  gr.  ■^,  by  whicli  time  the  patient  had  recovered  complete  power  over  the 
voluntary  muscles.  Two  days  later  gr.  ^  was  administered,  and  then  there  was  no 
return.  (Brit.  Med.  Jonrn.,  June  loth,  1878,  p.  857.)  In  a  chronic  case  of  chorea, 
which  was  admitted  into  the  Samaritan  Hospital  under  my  care,  in  October,  1878,  I 
determined  to  try  the  curara.  The  patient  was  a  girl  eleven  years  of  age,  and  had 
been  under  my  care  on  three  previous  occasions  for  the  same  disease.  There  was  in- 
cessant agitation  of  the  arms  and  legs,  and  it"  was  necessary  to  keep  her  in  bed.  The 
heart's  action  was  rather  thumping  and  excited,  and  there  was  a  soft  systolic  bruit  over 
the  apex.  After  taking  hypophosphite  of  soda  and  iron,  as  well  as  cod-liver  oil,  she 
was  not  manifestly  better,  and  any  excitement  or  talking  would  make  her  very  fidgety, 
and  increase  the  muscular  movements.  On  the  15th  of  October  1  injected  into  the 
right  forearm  gr.  g\j  of  curara  with  tiie  following  effect:  16th. — 10  A.M.,  no  effect;  11 
A.M.,  gr.  J^  injected ;  2.30  p.m.,  no  change,  pulse  72,  gr.  -^^  injected ;  6.45,  since  the 
injection  she  has  been  much  quieter,  and  lying  perfectly  still  with  complete  command 
over  the  limbs,  pulse  80,  inclined  to  sleep.  17th. — She  had  an  excellent  night,  and 
slept  better  than  she  had  done  for  some  time  past,  but  agitation  was  returning  in  the 
arms,  and  I  now  injected  gr.  ^q  at  10.45 ;  at  6.45,  as  there  was  no  further  improve- 
ment, I  injected  gr.  -^jj.  18th. — Slept  well,  quite  steady  in  arms  and  legs;  injected 
gr.  j^j.  19th. — 2  P.M.,  she  had  remained  quiet ;  gr.  Jg  injected.  20th. — No  injection 
used,  but  after  2  p.m.  the  limbs  became  more  agitated,  and  the  muscles  of  her  face  were 
more  in  action.  2 1st. — The  mouth,  hands,  and  legs  were  moving  more.  The  effect  of 
the  curara  has  been  to  keep  her  quiet  for  twenty-four  hours,  and  then  it  passed  off.  I 
must  admit  that  the  drug  partially  answered  my  expectations,  and  I  sliould  be  disposed 
to  employ  it  again  when  the  agitation  is  great,  because  it  controlled  the  movements, 
and  caused  neither  headache,  sickness,  nor  any  unpleasant  symptom.  One  difficulty  is 
the  alarm  which  the  injection  causes.  I  now  gave  sulphate  of  zinc,  beginning  with 
three  grains  three  times  a  day,  and  gradually  increasing  to  forty  grains  twice  a  day, 
without  causing  sickness,  nausea,  or  loss  of  appetite.  The  effect  of  this  treatment  was 
to  cause  a  great  deposit  of  phosphates  in  the  urine,  but  the  remedy  in  these  large  doses 
did  more  good  than  any  other  that  was  employed. 

*  Bull.  Gener.  Therapeutique,  Aug.  3d,  1876. — Quoted  from  the  Practitioner,  Oc- 
tober, 1876. 

t  Practitioner,  March,  1877,  p.  173.     By  Eobert  Bridges,  M.B.,  Oxon. 


634  DISEASES    OF    CHILDEEN. 

than  the  second,  and  so  on  till  the  amount  of  sleep  had  been  ob- 
tained, when  the  chloral  was  discontinued  till  the  next  night.  Of 
two  patients  so  treated,  aged  18  and  20,  one  was  completely  cured 
in  one  day,  and  the  other  on  the  fourth  day.  In  a  case  of  acute 
chorea  in  a  girl,  aged  nine,  I  found  five  grains  every  night  produce 
most  tranquil  sleep,  and  it  was  not  necessary  to  continue  it  after 
one  week.  In  another  case,  a  girl  of  13,  took  ten  grains  every 
two  hours  at  first,  and  afterwards  every  four  hours.  The  effects 
were  to  procure  sound  sleep,  which  she  had  not  obtained  for  a 
week  before  admission  into  hospital,  to  raise  a  small  and  weak 
pulse  of  64  to  76,  and  to  calm  the  muscular  movements.  Good 
diet,  and  four  ounces  of  sherrj',  were  given  daily.  When  sleep  was 
obtained,  the  cure  was  completed  with  iron,  and  large  doses  of 
sulphate  of  zinc. 

There  is  no  question  whatever  that  hydrate  of  chloral  is  a  valua- 
ble remedy  in  some  cases  of  chorea,  particularl}^  in  those  where 
vascular  excitement  is  present,  and  the  pulse  is  good.  Dr.  Althaus 
considers  that  the  theory  of  chorea  is  explained  by  active  hypere- 
mia of  the  corpora  striata,  and  the  parts  surrounding  the  fissure 
of  Sylvius,  and  that  the  beneficial  action  of  hydrate  of  chloral 
is  to  be  attributed  to  the  anemia  which  it  produces  in  these  struc- 
tures. Its  dangers  ^s  a  depressant  are  nothing  compared  to  the 
repose  andj^est  which  it  insures  to  the  nervous  system,  lessening 
as  it  does  in  suitable  doses  the  extreme  agitation  of  the  limbs, 
and  the  violence  of  the  choreic  movements.  Sleep  so  obtained 
gives  the  necessary  time  for  repair  to  the  overexcited  parts,  and 
will  be  found  to  succeed  when  morphia  yields  no  result.  The 
patient  wakes  able  to  swallow  food,  which  he  may  not  have  done 
for  weeks  or  months.  If  then  there  is  delirium  or  sleeplessness, 
chloral,  opium,  or  morphia,  to  allay  mental  excitement  and  pro- 
cure rest,  will  be  needed. 

In  some  cases,  where  the  disease  has  lasted  a  very  long  time,  the 
patient  passes  into  that  stage  of  chronic  chorea  or  agitation  which 
is  likely  to  becon:ie  permanent,  and  there  is  no  further  prospect  of 
benefit  from  treatment.  The  only  thing  to  be  done  in  these  cases 
is  to  maintain  as  far  as  possible  the  general  health,  and  to  avoid 
the  strain  of  school-work;  and  as  puberty  is  reached  the  disease 
may  be  thrown  oft'  altogether.  Bearing  in  mind  that  the  disease 
is  one  which  rapidly  induces  exhaustion,  the  constant  supply  of 
nutritious  food,  easy  of  digestion,  is  imperatively  demanded.     The 


CHOREA   OR   ST.  VITUS's    DANCE.  Go5 

free  employment,  too,  of  stimulants  may  be  necessary  to  support 
the  nervous  waste.  I  found  the  liberal  use  of  brandy  prove  of 
great  benefit  to  a  girl,  eight  years  of  age,  who  was  much  exhausted 
from  perpetual  agitation  of  the  limbs. 

Iron  is  one  of  the  best  remedies  we  possess  in  chorea,  and  mild 
cases,  especiall}'  if  there  is  anaemia,  often  yield  to  it.  Where  the 
movements  are  slight,  some  preparation  of  iron  maj'  be  given 
alone,  and  most  of  such  cases  will  be  cured  by  it.  When  the 
movements  are  frequent,  the  addition  of  bromide  of  potassium  is 
an  excellent  formula.  The  bromide  may  be  combined  in  these 
cases  with  the  ammonio-citrate  of  iron,  the  syrup  of  phosphate  of 
iron,  or  the  citrate  of  iron  and  quinine.  The  syrup  of  the  iodide 
of  iron  is  a  preparation  very  highly  reaommended  by  some  authori- 
ties. It  was  first  proposed  hj  the  late  Dr.  Barlow,  and  given  by 
him  with  great  success. 

Arsenic  is  a  valuable  remedy,  improving  nutrition  and  acting  as 
an  admirable  tonic.  Children  bear  comparatively  much  larger 
doses  of  this  drug  than  adults,  five  minims  being  generally  the 
minimum  dose.  Several  cases  have  appeared  to  me  to  yield  to 
arsenic  when  given  in  plain  water,  and  there  is  certainly  evidence 
to  show  that  it  is  a  very  efiicacious  drug  when  continued  long 
enough  and  in  sufficient  quantities,  small  doses  sometimes  failing 
when  large  succeed.  Dr.  Ringer  says,  that  "in  simple  uncompli- 
cated cases  of  chorea,  arsenic  is  by  far  the  best  remedy."*  Dr. 
Begbie,  after  an  experience  of  nearly  thirty  years,  never  knew 
this  remedy  to  fail.f  Few  physicians  can,  I  think,  speak  in  such 
enthusiastic  terms  of  it.  Although  in  my  hands  it  has  failed 
over  and  over  again,  I  am  quite  ready  to  admit  that  it  sometimes 
proves  successful  after  other  drugs  have  been  tried  in  vain,  if  given 
in  sufficient  doses.  A  choreic  girl,  nine  years  of  age,  who  was 
under  my  care  in  1880,  took  ten  minims  three  times  a  day  for 
twenty-three  successive  daj^s,  when  recovery  was  complete.  Five- 
minim  doses  did  no  good  whatever.  Where  anaemia  is  present, 
the  citrate  of  iron  and  quinine,  or  the  ammonio-citrate  of  iron,  or 
steel  wine,  may  be  combined  with  the  arsenic. 

Strychnia  has  been  employed  by  Trousseau,  and  as  a  nerve  tonic 
it  is  rational  to  suppose  that  it  will  prove  serviceable  in  certain 
cases.     But  its  tendency  to  cause  twitching  of  the  muscles,  which 

*  Handbook  of  Therapeutics,  4tli  edit.,  p.  260. 
t  Contributions  to  Practical  Medicine,  1S62,  p.  90. 


636  DISEASES   OF   CHILDREN. 

it  will  do  iu  some  cases,  even  in  very  small  doses,  renders  it  a 
doubtful  remedy  in  this  affection. 

Sul'plmte  of  Zinc. — I  have  given  this  drug  in  doses  of  from  one 
to  five  grains  three  times  a  day,  and  continued  it  for  a  week  with- 
out producing  au}^  effect,  and  the  remedy  so  repeatedly  disap- 
pointed me  that  for  some  time  I  ceased  to  employ  it.  This  most 
likely  arose  from  giving  it  in  too  small  a  dose.  Sir  T.  Watson 
gave  it  successful]}^  in  ten-grain  doses  three  times  a  day  in  a  severe 
case  which  had  resisted  other  remedies.  There  can  be  no  doubt 
that  zinc  sometimes  succeeds  where  iron  and  other  remedies  fail. 
In  prescribing  it,  the  dose  should  not  exceed  a  grain  three  times 
a  day  to  begin  with,  and  should  gradually  be  increased  till  there 
is  nausea  or  vomiting,  or  an  amelioration  of  the  symptoms.  In  a 
chronic  case,  which  was  temporarily  relieved  by  the  hypodermic 
injection  of  curara,  I  began  with  two-grain  doses  twice  a  day,  in- 
creasing the  dose  daily,  till  on  the  ninth  day,  the  girl,  seven  years 
of  age,  was  taking  eighteen  grains.  For  the  first  time  this  con- 
trolled the  agitation,  improved  her  voice  and  appearance,  and 
caused  no  sickness.  On  the  tenth  daj',  she  took  twenty  grains 
three  times  a  da3^,and  on  the  twelfth  day  fort}-  grains  twice  a  day, 
without  causing  the  least  unpleasant  sjmiptom.  The  heart,  which 
on  admission  was  rather  unsteady,  with  a  soft  apex  bruit  (owing 
to  debility),  became  quiet  and  regular,  and  the  murmur  entirely 
disappeared.  Among  the  chief  signs  of  improvement  was  the 
strength  of  her  voice,  the  ease  with  which  she  answered  questions, 
and  the  control  she  had  over  the  tongue  and  facial  muscles.  In 
another  similar  case  no  benefit  resulted,  and  the  patient  only  be- 
came a  little  sick  after  taking  ninety-six  grains  in  one  day. 

Sulphate  of  copper  is  used  by  Italian  physicians  for  chorea. 

Phosijliorus  in  combination  with  iron  is  a  good  nervine  tonic, 
and  when  persistent  anaemia  is  present  it  should  be  employed.  It 
often  takes  the  place,  or  even  supersedes  the  use  of  iron,  restoring 
the  tone  of  the  nervous  functions,  and  improving  the  quality  of 
the  blood.  Dr.  Radclifle  speaks  highly  of  the  hypophosphite  of 
soda.  He  says,  "  I  have  given  for  some  time  from  five  to  eight 
grains,  three  times  a  day,  of  the  hypophosphite  of  soda  to  children 
in  cases  of  chorea,  without  any  harm  certainly,  and,  as  I  think, 
with  unmistakable  benefit,  and  I  have  not  yet  found  any  reason 
to  change  this  practice  for  another."  In  ordinary  cases  he  also 
gives  cod-liver  oil  with  the  hypophosphite  of  soda,  and  adds  cam- 


DISEASES   OF   THE  SPINAL   CORD.  G37 

phor,  or  carbonate  of  ammonia,  or  both,  according  to  circumstances. 
Of  sixty  cases  so  treated,  the  average  duration  of  treatment  was 
under  one  month.*  I  have  frequently  given,  with  advantage,  five 
grains  of  the  hypophosphite  of  lime  and  one  drachm  of  the  syrup 
of  phosphate  of  iron  in  a  tablespoonful  of  water  twice  a  day. 

Quinine  and  bark  are  useful  in  their  turn,  and  cod-liver  oil  is 
one  of  the  best  remedies. 

I  have  never  employed  tartarated  antimony  in  any  dose,  nor  can 
I  see  a  reason  for  supposing  that  it  could  prove  of  real  utility.  It 
seems  a  remedy  likely  to  do  harm  from  its  depressing  efi'ect,  though 
cases  are  recorded  in  which  it  has  done  good.  Dr.  West  has  given 
"as  much  as  nine  grains  of  it  in  one  day  for  three  days  together, 
with  no  sensible  influence  on  the  pulse,  no  sickness,  and  no  diar- 
rhoea, but  with  very  remarkable  abatement  of  the  movements. "f 

Finally,  sea  air,  shower-baths,  cold-water  douches,  gymnastic 
exercises,  are  useful  in  properly  selected  cases.  Galvanization  and 
faradization  are  also  to  be  recommended.  A  gentle  constant 
current,  applied  for  four  or  five  minutes  to  the  sufi:ering  portion 
of  the  brain,  generally  arrests  the  choreic  movements  at  once.  In 
hemichorea  the  opposite  side  of  the  brain  must  be  galvanized. 


CHAPTER   XLYI. 

DISEASES   OF    THE    SPINAL    CORD. 

Spinal  Irritation.  Spinal  Hemorrhage.  Spinal  Meningitis:  Symptoms — 
Pathology  and  treatment.  Myelitis:  Symptoms — Causes  and  treatment.  Cerebro- 
spinal Meningitis  (Cerebro-spinal  Fever). 

Affections  of  the  spinal  cord  are  obscure  at  all  ages,  and  they 
are  more  so  in  young  subjects  than  in  adults ;  for  whilst  in  the 
latter  any  impairment  of  motor  power  or  abnormal  sensations 
would  be  at  once  complained  of,  in  the  former,  serious  mischief 
might  proceed  for  some  time  before  we  are  able  to  detect  it. 

It  must  also  be  admitted  that  examination  of  the  spinal  cord 
and  its  membranes  after  death  is  most  unsatisfactory.     The  body 

*  Chorea,  by  C.  H.  B.  Radclifie,  M.D.,  Reynolds'a  System  of  Medicine,  vol.  ii,  2d 
edit.,  p.  220. 

t  On  Some  of  the  Disorders  of  the  Nervous  System  in  Childhood,  1871,  p.  73. 


638  DISEASES    OF   CHILDREN". 

allowed  to  remain  on  the  back  facilitates  the  gravitation  of  blood 
and  fluids  into  the  most  depending  parts,  by  which  the  nervous 
tissue  itself  is  altered,  and  the  evidences  of  congestion  and  efiusion, 
which  are  hastily  attributed  to  disease,  may  be  entirely  due  to 
position.  This  fact  has  struck  most  observers,  and  rendered  an 
explanation  of  the  changes  discovered  after  death  very  confusing, 
and  calculated  to  mislead.  "  First  of  all,  as  regards  the  much- 
abused  hyperfemia,  all  post-mortem  appearances  must  be  excluded 
as  spurious  where  the  body  was  not  placed  upon  its  face  imme- 
diately after  death,  and  the  autopsy  was  performed  later  than 
twenty-four  hours  after  life  terminated.  Without  this  precaution 
there  will  be  found  in  every  case,  even  in  the  most  normal,  exten- 
sive post-mortem  hypostasis,  imbibition  of  the  coloring  matter  of 
the  blood,  and  putrid  softening,  by  which  it  becomes  totally 
impossible  to  establish  the  previous  existence  of  any  actual  disease 
in  the  medulla  spinalis."* 

Spinal  Irritation. — "  We  have  no  more  right  to  refuse  to  spinal 
irritation  the  claim  to  a  separate  existence,  simply  on  the  ground 
of  the  want  of  a  known  basis  of  anatomical  lesion  in  the  cord, 
than  we  have  to  do  the  same  in  acute  ascending  paralysis,  in 
tetany,  and  many  other  diseases  which  betray  an  equally  imperfect 
knowledge  of  pathological  anatomy. "f  The  symptoms  that  denote 
this  condition  are  more  or  less  impairment  of  motion  in  the  U]3per 
or  lower  extremities,  according  to  the  seat  or  degree  of  mischief 
that  may  be  present.  There  is  pain  of  an  obscure  character  in 
the  cervical  or  lumbar  region,  languor,  and  failing  health.  In 
some  cases  the  pain  is  severe  enough  to  simulate  disease  of  the 
vertebrpe  ;  there  may  be  tenderness  along  the  spine,  and  even 
some  puffiness,  and  the  degree  of  congestion  may  be  sufficient  to 
produce  more  or  less  stiffness  of  the  neck,  and  pain  on  nloving  the 
head. 

Dr.  West  describes  the  case  of  a  little  boy,  two  and  a  half  years 
old,  who  had  irritation  of  the  spinal  cord  from  masturbation  ;  he 
tottered  in  his  gait,  was  indisposed  to  move,  and  at  last  almost 
entirel}^  ceased  to  walk.  When  the  bad  practice  to  which  he  was 
addicted  was  put  a  stopj  to,  he  soon  regained  his  health  and  the 
power  of  walking.:}: 

"  Vo^el,  Dl&eitseb  of  Children,  1874,  p.  376. 

f  Zierus-^en's  Cvclopredia  of  Meflicine,  1878,  vol.  xiii,  p.  359. 

X  Diseases  of  Infancy  and  Childhood,  1859,  p.  102. 


DISEASES   OF   THE   SPINAL   CORD.  639 

He  also  relates  two  other  cases  in  cliildren  of  four  and  five  years 
of  age.  In  one  case  the  symptoms  began  with  failing  health  and 
stift'ness  of  the  neck,  succeeded  by  the  head  being  thrown  back 
and  motionless,  pressure  over  the  cervical  vertebrae  gave  pain,  and 
the  appearance  and  manner  of  the  patient  seemed  to  point  to  dis- 
ease of  the  cervical  vertebrae.  The  application  of  four  leeches  to 
the  back  of  the  neck  was  followed  by  sleep,  and  next  morning 
there  was  no  pain  in  the  head,  or  tenderness  of  the  spine,  and 
complete  power  over  the  muscles  of  the  neck. 

In  the  other  case,  the  child  had  a  fall  on  her  back  ten  days  be- 
fore she  was  seen  by  Dr.  West.  The  day  following  the  fall  she 
was  unable  to  stand  or  move  without  support,  and  had  continued 
in  the  same  state  ever  since.  There'  was  heat  of  skin,  frequent 
pulse,  loss-  of  appetite,  thirst,  and  furred  tongue  ;  the  bowels  were 
constipated,  hut  the  urine  was  normal.  The  integuments  from 
the  tenth  to  the  twelfth  dorsal  vertebrae  were  puffy,  and  there 
were  pain  and  tenderness  over  the  spine  in  this  situation.  Cup- 
ping to  four  ounces  over  the  loins  was  followed  next  day  by  relief 
of  the  pain,  and  the  power  of  moving  her  legs  more  readily.  She 
recovered  in  a  few  days. 

Spinal  Hcemorrhage. — Cases  of  spinal  apoplexy  in  children  are 
on  record.  "  Dr.  Abercrombie  gives  a  single  instance,  which  oc- 
curred under  his  own  observation,  in  a  child  aged  seven  years,  in 
whom,  after  an  illness  of  three  days,  death  ensued  from  violent 
convulsions.  A  long  and  very  firm  coagulum  of  blood  was  found, 
external  to  the  cord,  extending  the  whole  length  of  the  cervical 
portion."* 

Apoplexy  of  the  spinal  membrane  (like  the  cord  itself)  is  so  rare 
that  Wilks  and  Moxon  have  never  met  wdth  it.f  Still  it  occa- 
sionally occurs,  causing  paraplegia  and  other  symptoms,  arising 
from  pressure.  The  symptoms  are  violent  pain  in  the  region  of 
eflusion,  general  convulsions,  and  speedy  death. 

Sjmial  Meningitis. — As  the  membranes  of  the  brain  are  liable  to 
acute  and  chronic  inflammation,  so  are  those  that  invest  the  spinal 
cord.  Spinal  meningitis  appears  to  be  more  common  in  new-born 
infants  than  in  adults,  and  is  considered  to  be  jDyremic.  "  Billard 
found  that  in  thirty  cases  of  convulsions  there  was  meningitis  of 

*  Jones  and  Sieveking's  Pathological  Anatomy,  by  Payne,  1875,  p.  292. 
f  Pathological  Anatomy,  1875,  p.  246. 


640  DISEASES   OF   CHILDEEN. 

the  cord  in  twenty,  only  six  of  wliicli  presented  inflammation  of 
the  cerebral  meninges."* 

Acute  inflammation  of  the  dura-arachnoid  {'pachy-meningiiis)  is 
rare ;  it  may  arise  from  disease  of  the  vertebras  extending  to  the 
membranes,  or  from  exposure  to  damp  and  cold,  and  from  injuries. 
Meningitis,  with  an  efl:usion  of  pus  and  fibrinous  serum,  has  fol- 
lowed acute  articular  rheumatism. f 

Spinal  meningitis,  causing  paralysis,  has  followed  diphtheria, 
typhoid  fever,  small-pox,  and  occasionally  scarlet  fever.  An  excel- 
lent paper  has  been  written  on  this  subject  by  Dr.  Althaus.:}: 

"A  lad  received  a  blow  over  the  loins;  an  abscess  formed  which 
involved  the  vertebrae,  and  the  purulent  matter  entered  the  spinal 
canal,  so  that  when  he  died,  three  weeks  afterwards,  the  arachnoid 
cavity  was  filled  with  pus,  and  the  inflammatory  process  had  pro- 
ceeded upwards  to  the  brain,  and  there  produced  also  an  arach- 
mtis."§  Spinal  meningitis,  in  two  cases  of  infants  aged  respec- 
tively^ three  and  four  weeks,  followed  the  injection  of  Morton's 
fluid  by  Mr.  Callender,  for  the  cure  of  spina  bifida.! 

The  symptoms  are  pain  in  the  course  of  the  spine,  which  may  be 
limited  to  the  cervical  or  dorsal  region,  and  increased  on  movement ; 
spasms  of  the  muscles,  eventual  loss  of  motion,  and  paralysis. 
This  latter  is  owing  to  compression  of  the  cord  by  the  eftusion, 
and  is  often  combined  with  bed-sores.  Sometimes  the  disease  ex- 
tends upwards  along  the  spinal  canal,  and  produces  inflammation 
of  the  cerebral  membranes.  The  disease  is  not  easy  to  distinguish 
from  inflammation  of  the  cord  itself. 

Pathology. — After  death  in  these  cases  the  dura-arachnoid  is 
found  thickened,  the  vessels  are  congested,  and  there  is  an  efl'usion 
of  serum  and  puriforra  lymph.  When  the  pia-arachnoid  is  likewise 
involved  {lexAo-menirigitis)  the  cord  has  an  irregular  appearance, 
owing  to  the  eftusion  of  lymph  within  the  arachnoid  space.  "Where 
the  inflammation  arises  from  disease  of  the  vertebrae,  and  other 
neighboring  structures,  it  appears  localized  in  certains  portions  of 
the  spine  ;  but  when,  owing  to  a  general  cause,  it  may  spread 
throughout  the  length  of  the  spine,  it  selects  always  the  posterior 
rather  than  the  anterior  surface.    On  cutting  the  arachnoid  lymph 


*  Jones  and  Sieveking's  Pathological  Anatomy,  by  Payne,  1875,  p.  294. 

t  Steiner's  Diseases  of  Children,  by  Lawson  Tait,  1874,  p.  66. 

t  Brit.  Med.  Journ.,  vol.  i,  1881,  p.  51. 

§  Wilks  and  Moxon,  Pathological  Anatomy,  1875,  p.  243. 

II  St.  Bart.  Hosp   Rept.,  vol.  xv,  p.  51. 


DISEASES   OF   THE   SPIXAL   CORD.  641 

is  found  beneath  of  a  yellowish-green  line,  toughish,  or  softer,  or 
even  puriform.* 

Treatment. — Leeching  over  the  seat  of  pain  and  mischief  in  the 
spinal  cord,  a  judicious  and  iinstimnlating  diet,  and  the  hypo- 
dermic injection  of  morphia  to  relieve  pain,  are  the  only  measures 
to  adopt. 

Myelitis^  or  inflammation  of  the  spinal  cord,  is  a  very  rare  dis- 
ease; it  generally  follows  an  injury  or  pysemia,  or  exposure  to 
cold.  Myelitis  can  be  produced  in  rabbits  by  freezing  the  hind 
legs  with  ether  spray,  and  according  to  Dr.  Althaus,  the  first 
effect  of  the  irritation  is  to  cause  spasm  and  then  paralysis  of  the 
bloodvessels  by  vaso-motor  influence.f  The  inflammation  may 
attack  the  whole  or  a  portion  of  the  cord,  and  hence  the 
sym})toms  vary  according  to  the  seat  of  the  disease.  There  is 
pain  in  the  back,  and  if  the  mischief  is  in  the  cervical  region, 
difficulty^  of  breathing.  The  disease  may  be  attended  with  inflam- 
mation of  the  brain  owing  to  the  extension  of  inflammation  from 
the  cord,  and  the  sympathy  existing  between  the  brain  and  spinal 
system.  With  the  advance  of  the  disease,  paralysis,  sloughing  of 
the  skin,  alkaline  and  albuminous  urine,  supervene.  Death  takes 
place  sooner  or  later,  and  if  life  is  prolonged,  there  is  paralysis  of 
motion  and  sensation  in  the  parts  below  the  seat  of  the  disease. 
It  often  terminates  in  softening  of  the  cord,  but  never  produces 
pus,  except  from  pyfemia. 

An  interesting  case  of  acute  softening  of  the  spinal  cord  is 
recorded  of  a  female  child,  11  years  of  age,  who  w^as  admitted 
into  the  Bristol  General  Hospital,  with  paraplegia,  under  the  care 
of  Dr.  Clark,  December  31st,  1873.  The  disease  began  a  week  before 
admission  with  shivering  and  pains  in  her  limbs,  but  she  went 
about  till  three  days  previous  to  entering  the  hospital,  when  she 
suddenly  lost  the  use  of  her  legs.  She  never  had  convulsions,  and 
there  was  no  history  of  any  injury  to  the  back.  There  was  pain 
along  the  vertebral  column  which  was  worse  in  the  cervical  region. 
It  was  not  increased  on  pressure,  and  she  could  move  her  head 
about  freely.  There  was  complete  paralysis  of  motion  of  the  lower 
extremities.  Sensation  was  diminished  in  the  right  lower  ex- 
tremity, and  there  w^as  no  sensation  in  the  left.     There  was  com- 

*  Wilks  and  Moxon,  op   cit.,  p.  245. 
t  Medical  Society's  Proceedings,  vol.  iv,  p.  7G, 
41 


642  DISEASES    OF   CHILDREN. 

plete  loss  of  power  over  the  bladder  and  rectum,  uric  acid,  lithates, 
no  albumen.  Optic  disks  normal.  The  highest  morning  temper- 
ature was  99.4°  ;  the  highest  evening  101°.  The  third  day  after 
admission  there  was  partial  paralysis  of  the  upper  extremities. 
On  the  fifth  day  there  was  more  pain  in  the  cervical  region.  On 
the  sixth  day,  the  urine  was  alkaline,  ammoniacal,  and  contained 
pus  and  albumen.  On  the  seventh  day,  the  paralysis  of  the 
extremities  had  increased,  difficult  breathing  and  congestion  of 
the  lungs  came  on.  On  the  tenth  day,  difficulty  of  l)reathing 
increased,  and  death  took  place.  ~       \ 

Post-mortem  Examinoiion. — The  cerebral  veins  were  congested 
and  there  were  several  points  of  injection  in  the  brain,  which  was 
otherwise  pale.  "  The  spinal  cord  weighed  f  ounce ;  the  membranes 
were  healthy  ;  there  was  a  quantity  of  serous  fluid  in  the  arach- 
noid sac  ;  the  cervical  portion  of  the  cord  was  firm,  but  on  making 
a  transverse  section  there  were  several  points  of  injection  in  it ; 
lungs  congested;  pleuritic  adhesions  on  the  right  side.  The  heart 
weighed  4J  ounces,  and  was  healthy.  Liver,  spleen,  and  kidneys 
normal,  but  intensely  congested.  Stomach,  intestines,  uterus,  and 
ovaries  normal.  The  bladder  was  in  a  state  of  acute  suppurative 
inflammation;  the  coat  was  very  much  thickened,  and  the  mucous 
membrane  lining  the  interior  was  covered  with  a  yellowish-gray 
slongh."* 

Ireatment  of  Myelitis. — The  subcutaneous  injection  of  ergotine, 
as  in  the  inflammatory  stage  of  infantile  paralysis,  is  recommended 
by  Dr.  Althaus,t  and  when  inflammation  has  subsided,  iodide  of 
potassium  to  promote  the  absorption  of  any  effused  fluids  and 
morbid  products.  Later  on,  cod-liver  oil,  phosphorus,  friction, 
shampooing,  and  electricity  will  be  found  serviceable. 

An  interesting  case  of  elongated  cavity  in  the  spinal  cord  {Syringo- 
myelics) is  recorded  by  Dr.  Frederick  Taylor,  of  a  female  child, 
aged  eighteen  months,  who  was  well  till  the  age  of  five  months, 
when  it  could  not  hold  up  its  head,  and  from  that  time  the  head 
enlarged.  On  admission  into  the  Evelina  Hospital,  November  19th, 
1877,  the  arms  became  completely  paralyzed.  The  head  presented 
the  characteristic  signs  of  chronic  hydrocephalus,  and  was  very 
large.  The  anterior  fontanelles  and  anterior  sutures  were  widely 
open  ;  the  eyeballs  prominent,  optic  disks  white,  and  vessels  of  the 

*  Acute  Softening  of  Spinal  Cord,  Lancet,  vol.  i,  1874,  p.  442. 
f  See  Chap.  XLVII,  On  Infantile  Paralysis. 


DISEASES    OF    THE    SPINAL   CORD.  643 

usual  size.  Arms  motionless  and  flaccid,  legs  distinctly  rigid. 
Ttie  child  got  an  attack  of  measles  in  ISTovember,  and  died  of 
bronchopneumonia  on  December  5th. 

The  post-mortem  revealed  pleuritic  effusion  on  both  sides,  and 
lobular  pneumonia  at  the  base  of  the  lungs.  A  pint  and  a  half  of 
fluid  was  obtained  by  a  trochar  through  the  anterior  fontanelle ; 
the  ventricles  were  greatly  distended,  and  the  fourth  ventricle 
was  large  enough  to  contain  a  small  walnut.  "  The  membranes 
of  the  spinal  cord  were  healthy.  The  cervical  and  lumbar  regions 
had  their  usual  consistence,  but  the  dorsal  region  was  quite  flaccid, 
and  on  makino;  transverse  sections  it  was  seen  that  in  this  res^ion 
the  cord  was  hollowed  by  a  considerable  cavity.  The  largest 
cavity  (for  there  were  altogether  three)  was  of  irregular  size  and 
shape,  and  altogether  extended  from  the  lowest  part  of  the  cervical 
to  the  highest  part  of  the  lumbar  region,  and  was  two  and  a  half 
inches  in  length."*  These  cavities  did  not  correspond  with  the 
central  canal  of  the  cord.  Dr.  Taylor  quotes  observations  of  other 
authors  on  this  rare  condition.  This  case  is  essentially,  as  far  as 
clinical  features  show,  an  instance  of  hydrocephalus.  JSTo  symp- 
toms that  were  observed  can  guide  us  to  the  suspicion  of  a  similar 
state  of  the  cord  in  other  patients  ;  neither  must  we  forget  that 
in  making  post-mortem  examinations  of  the  brain,  the  cord  is 
seldom  examined,  hence  the  presence  of  cavities  may  be  more 
common  than  is  supposed. 

Cerehro- spinal  Meningitis. — This  formidable  and  fatal  disease  is 
of  sufiicient  frequency  and  importance  to  be  alluded  to.  Young 
persons  are  most  liable  to  it,  and  children  are  not  infrequently 
attacked.  The  disease  has  prevailed  in  the  chief  countries  of  the 
Continent,  as  well  as  in  England,  Ireland,  and  America. 

It  would  seem  to  be  entitled  to  rank  among  the  specific  dis- 
eases, for  it  often  occurs  as  an  epidemic ;  it  has  a  fatality  like 
typhus,  which  it  resembles ;  it  is  due  to  blood-poisoning,  and  not 
infrequently  there  is  a  petechial  rash. 

The  causes  appear  to  be  due  to  cold  and  exposure,  fatigue,  bad 
living,  and  insanitary  conditions,  like  typhus,  but  it  is  not  con- 
tagious. 

The  sym'ptoms  begin  with  rigors,  followed  by  fever,  severe  pain 
in  the  back  of  the  head,  extending  along  the  spine,  and  stiffness 
of  the  cervical  muscles.     Nausea  and  vomiting  are  usually  severe. 

*  Pathological  Transactions,  vol.  xxix,  p.  21. 


644  DISEASES   OF   CHILDEEN. 

In  some  cases  described,  the  child  falls  into  a  state  of  stupor,  moans 
or  cries,  and  then  becomes  unconscious,  with  a  dusky  countenance, 
from  which  state  it  does  not  recover.  In  other  cases  the  intellect 
remains  clear.  The  head  is  thrown  backwards  towards  the  spine, 
and  there  is  tetanic  stiffness  of  the  muscles,  paralj'sis,  and  even 
convulsions.  Disordered  vision  is  not  uncommon.  The  tempera- 
ture runs  up  to  lO-i"^,  or  even  higher  in  some  cases  ;  the  pulse  is 
quick  and  small ;  the  tongue  furred,  the  urine  scanty,  and  some- 
times albuminous.  Petechial  spots  are  seen  over  the  face,  neck, 
chest,  and  limbs,  of  variable  size,  and  disappearing  on  pressure. 
Herpes  on  the  lips  is  often  noticed  in  connection  with  the  disorder, 
particularly  in  mild  cases.  The  disease  may  terminate  fatally  in 
a  few  hours,  or  it  may  last  over  a  week. 

"  Spinal  meningitis  is  by  no  means  rare  in  association  with 
tubercnlar  cerebral  meningitis ;  and  it  is  quite  possible  that  some 
cases  of  so-called  '  cerebro-spinal  fever '  in  children  are  really 
dependent  upon  tuberculosis,  just  as  others  may  originate  from 
traumatic  causes."* 

From  a  number  of  cases  admitted  into  the  Dundee  Infirmary, 
in  December,  1877  and  1878,  Dr.  Maclagan  regards  the  disease  as 
contagious,  and  bearing  a  great  resemblance  to  typhus.  It  sets 
in  with  rigors,  intense  headache,  pains  in  the  neck,  limbs,  and 
trunk.  There  is  fever,  and  the  respiration  is  quick  and  cerebral 
in  character;  the  patient  is  restlesB ;  the  tongue  dry  and  furred  ; 
■urine  high-colored,  deficient  in  chlorides,  and  sometimes  contains 
albumen.  When  an  eruption  is  present  on  the  skin  it  resembles 
the  rash  of  typhus,  but  it  appears  earlier,  and  is  lighter  in  color. 
The  cuticle  desquamates  freely  after  cerebro-spinal  fever.  The 
writer  says  it  is  distinguished  from  typhus  by  more  sickness  at 
the  onset  and  more  headache,  the  intellect  is  often  clear  throughout 
the  illness,  and  there  is  a  less  tendency  to  delirium.f  The  resem- 
blance, however,  appears  to  me  very  close.  The  morbid  appear- 
ances found  after  death  were  inflammation  of  the  membranes  of 
the  nervous  centres,  lymph,  and  fluid  effusion  into  the  arachnoid, 
and  intense  injection  of  the  vessels  of  the  pia 'mater.  The  veins 
in  the  spinal  cavity  were  fall,  and  there  was  vascularity  of  the 
membranes  of  the  cord.  One  case  terminated  fatally  in  rupture 
of  the  spleen."]: 

*  Cerebro-spinal  Meningitis,  editorial,  the  Lancet,  1876,  vol.  ii,  p.  57. 
t  Cerebro-spinal  Fever,  the  Lancet,  vol.  i,  1878,  p.  219. 
X  Ibid.,  1878,  p.  822. 


DISEASES    OF   THE    SPINAL   CORD.  645 

In  a  case  recorded  by  Dr.  H.  Vandyke  Carter,  of  Bombay,  the 
patient  was  semiconscious  from  the  first.  On  the  third  day  he 
became  insensible,  and  died  on  the  fifth  day.  At  the  post-mortem 
examination  the  meninges  were  greatly  congested,  and  over  the 
convexity  of  the  hemispheres  was  a  layer  of  greenish-yellow  pus; 
the  spinal  subarachnoid  space  was  occupied  with  puriform  lymph 
like  that  in  the  brain,  and  the  effusion  was  almost  limited  to  the 
posterior  surface  of  the  cord.* 

The  favorable  symptoms  which  precede  recovery  are  a  cessation 
of  pain  and  fever,  relaxation  of  the  muscles  of  the  neck,  undis- 
turbed sleep,  and  returning  appetite. 

The  diagnosis  is  mainly  grounded  on  the  typhoid  symptoms,  the 
epidemic  character  of  the  disease,  and  the  cerebral  and  spinal  symp- 
toms.    The  prognosis  is  extremely  unfavorable. 

The  morbid  appearances  found  after  death  are  great  congestion 
of  the  cerebral  vessels,  and  effusion  into  the  ventricles  ;  coagulated 
blood  in  the  sinuses  of  the  dura  mater,  and  an  exudation  of  serum 
or  pus  among  the  meninges  of  the  brain.  Very  similar  appear- 
ances are  presented  in  the  membranes  of  the  spinal  cord.  "  But 
when  the  case  is  as  usual  of  mitigated,  yet  fatal,  severity,  you  find 
it  a  pia-arachnitis,  the  lymph  lying  chiefly  on  the  dorsal  surface  of 
the  pia  mater.  Only  in  the  very  rarest  cases  do  any  products  ap- 
pear in  the  arachnoid  space.  The  spinal  cord  itself  in  this  disease 
is  often  quite  free  from  change."f  There  are  also  sometimes  evi- 
dences of  congestion  and  inflammation  in  the  lungs,  pleura,  and 
pericardium,  enlargement  of  the  spleen,  fatty  degeneration  of  the 
liver  and  kidneys,  and  occasional  enlargement  of  Peyer's  patches. 

Treatment. — Hitherto  this  has  been  most  unsatisfactory,  various 
methods  having  been  tried,  with  small  success.  Leeches  behind 
the  ears,  or  cupping  along  the  spine  may  be  demanded  in  some 
cases.  Cold  applications  to  the  head  and  spine  have  also  been 
found  serviceable.  At  the  onset,  where  there  is  high  fever  and 
delirium,  the  head  may  be  shaved,  cold  applied,  and  calomel  given 
&yQYj  four  hours.     The  hypodermic  injection  of  morphia  to  relieve 

*  Note  on  the  Occurrence  of  Cerebro-spinal  Meningitis,  Lancet,  vol.  ii,  1878,  p. 
730. 

f  Wilks  and  Moxon's  Pathological  Anatomy,  1875,  p.  246. 

In  the  case  of  a  girl,  13  years  of  age,  admitted  into  the  Hitchin  Infirmary,  the  spi- 
nal cord  in  the  lower  cervical  and  upper  dorsal  vertebrae  was  softened,  and  about  the 
consistence  of  cream. — Lancet,  vol.  i,  1876,  p.  814. 


646  DISEASES   OF   CHILDREN. 

pain,  hydrate  of  chloral  to  procure  sleep,  and  bromide  of  potassium 
to  quiet  the  nervous  sj^stem  are  severally  indicated  according  to 
the  peculiar  circumstances  of  each  case.  If  typhoid  symptoms  are 
present,  quinine  should  be  resorted  to,  and  as  a  rule,  enemata,  nu- 
tritious food,  and  stimulants  will  be  required. 

Sexual  precocity  or  aberration  is  found  in  some  children.  The 
subject  is  a  verj':  disagreeable  one,  but  its  consideration  cannot  be  en- 
tirely omitted  from  a  work  of  this  kind.  In  boys  the  practice  of 
masturbation  may  be  caused  by  irritation  produced  by  a  long  pre- 
puce ;  in  girls  it  is  undoubtedly  due  in  many  cases  to  the  irritation 
of  ascarides,  especially  when  they  escape  at  night  from  the  anal 
ring  and  wander  into  the  vaginal  orifice.  The  little  girl  is  thus 
induced  to  scratch  herself,  and  so  in  time  the  habit  is  gradually 
formed.  In  both,  the  practice  may  be  communicated  by  other 
children,  who  have  acquired  the  vicious  habit;  at  other  times 
it  is  to  be  feared  the  practice  is  brought  about  by  the  improper 
conduct  of  nurses,  and  especially  Indian  ayahs.  When  a  child  is 
fretful,  the  irritation  of  its  genitals  distracts  it,  and  the  excitement 
so  produced  is  followed  by  languor  and  sleep.  Occasionally,  in 
girls,  it  results  from  vaginitis,  as  a  result  of  dirty  habits  and 
general  neglect.  In  such  cases,  carelessness  on  the  part  of  the 
mother  is  much  to  blame.  Where  clonic  spasms  and  paralysis  are 
the  consequence  of  this  habit  in  boys,  to  touch  the  meatus  by  a 
probe  is  usually  followed  by  almost  instantaneous  erection  of  the 
penis,  ancl  by  convulsive  movements.  The  increasing  development 
of  the  nervous  system  in  both  sexes,  and  the  consequent  tendency 
to  precocity,  makes  one  fear  that  this  evil  practice  is  becoming 
more  common.  If  such  is  the  case,  it  is  highly  incumbent  upon 
parents  and  guardians  to  recognize  the  fact,  and  to  give  assiduous 
attention  to  the  morale  of  their  children  and  their  associates. 


INFANTILE   PARALYSIS.  647 

CHAPTER  XLYII. 

INFANTILE    PARALYSIS — ACUTE    ANTERIOR    POLIO-MYELITIS. 

Causes  :  Teething — Exposure  to  damp  and  cold — Eruptive  fevers — Blows  or  injuries  to  the 
hip — Chronic  illness.  Symptoms:  Sudden  or  gradual  loss  of  power  in  all  or  some  of 
the  muscles  of  one  or  several  limbs — Debility  and  slight  fever — No  headache,  sickness,  or 
convulsion  except  by  pure  coincidence — Paralysis  sudden  or  gradual,  but  at  length  com- 
plete— In  some  cases  transitory.  Pathology  :  Diffuse  acute  inflammation,  of  the  an- 
terior cornua  of  the  spinal  cord — Changes  rather  obscure  than  positive.  Treatment  : 
Hest  in  bed — Calomel — Leeches  and  cupping  to  spine  recommended — Subcutaneous  in- 
jection of  ergotin  —  Injection  of  strychnia  (Barwell) — Belladonna — Ergot  of  rye — 
Iodide  of  potassium — Constant  galvanic  current — Cod-liver  oil — Phosphorus — Sea-air 
— Good  diet.  Duchenne's  Paralysis:  Causes  —  Symptoms  —  Pathology — Treat- 
ment.    Neuralgia  :  Bare  in  children — Causes — Treatment. 

There  are  four  principal  forms  of  paralysis  in  children: 

1.  Obstetrical  paralysis. 

2.  Paralj'sis  from  brain  disease. 

3.  Infantile  paralysis  properly  so  called. 

4.  Duchenne's  paralysis. 

1.  Obstetrical  'paralysis  sometimes  occurs  from  pressure  of  one 
blade  of  the  forceps  on  the  portio  dura  at  its  exit  from  the  stylo- 
mastoid foramen.  During  the  operation  of  turning,  from  undue 
violence  the  brachial  plexus  may  be  torn  or  injured,  and  i3aralysis 
of  the  upper  extremity  is  produced.  If  any  undue  impairment  of 
the  cerebral  circulation  takes  place,  there  may  be  hasmorrhage  of 
the  corpus  striatum,  producing  all  the  ordinary  symptoms  of  cere- 
bral hemiplegia. 

2.  Paralysis  from  brain  disease  may  be  the  result  of  hydrocepha- 
lus, meningitis,  apoplexy,  and  cerebral  tumors.  I  once  met  with 
a  case  of  hemiplegia,  in  a  child  nineteen  months  old,  who  had  a 
subacute  attack  of  meningitis  and  recovered.  Paralysis  is  some- 
times the  result  of  rheumatism,  typhoid  fever,  diphtheria,  and 
especiallj^  scarlet  fever.  Disease  of  the  petrous  portion  of  the 
temporal  bone  may  produce  facial  paralysis.  Paralysis  may  occur 
during  dentition,  and  be  associated  with  convulsions  and  laryngis- 
mus stridulus. 

3.  Infantile.,  or  infantile  spinal  paralysis.,  is  a  disease  occurring 
in  young  children,  the  nature  of  which  has  not  been  satisfactorily 
investigated.     It  is  particularly  apt  to  attack  children  under  two 


648  DISEASES    OF   CHILDREN. 

years  of  age."^  It  is  a  motor  paralysis  only,  sensation  being  in  no 
way  aftected.  It  is  generally  sudden  in  its  accession,  is  attended 
with  febrile  symptoms,  and  ends  in  complete  paralysis  and  waist- 
ing  of  the  muscles.  The  limbs  are  not  necessarily  alone  affected ; 
the  muscles  of  the  back  may  be  involved,  and  the  spine  more  or 
less  curved.  It  is  generally  the  right  lower  extremity  that  is  at- 
tacked. The  brain  and  cranial  nerves  exhibit  no  morbid  appear- 
ances. 

Causes. — The  disease  may  appear  suddenly  in  children  who  have 
not  been  previousl}^  out  of  health,  or  who  have  not  suffered  from 
any  nervous  or  febrile  disorder.  Teething  is  not  an  uncommon 
cause.  A  child  who  came  under  my  care  with  infantile  paralysis 
in  January,  1B79,  walked  when  he  was  a  year  old;  he  then  par- 
tially lost  the  use  of  his  left  leg,  whilst  cutting  a  tooth.  At  two 
years  old,  when  I  first  saw  him,  he  could  walk,  but  was  lame,  and 
the  muscles  of  the  afiected  limb  were  wasted.  I  have  known  the 
attacks  follow  cold  and  ulceration  of  the  throat,  diphtheria,  and 
the  eruptive  fevers.  Blows  and  falls  upon  the  hip  have  produced 
this  form  of  paralysis.  In  rickety  subjects,  with  delayed  denti- 
tion, a  child  may  suddenly  lose  the  use  of  a  limb,  and  wasting  and 
contraction  continue  until  there  is  permanent  deformity,  such  as 
clubfoot,  necessitating  division  of  the  tendons.  A  child,  two 
years  of  age,  had  bronchitis  followed  in  six  weeks  by  measles.  A 
fortnight  later  paralysis  of  the  lower  limbs  came  on.  He  recovered 
quickly  under  the  use  of  iron,  strychnia,  and  shampooing.  The 
disease  may  succeed  convulsions  in  children,  and  irrecoverable  pa- 
ralysis may  ensue.  It  creeps  on  insidiously  in  some  cases,  especially 
in  excitable  children  who  come  of  nervous  parents.  A  little  girl, 
aged  seven  years,  under  my  care  in  February,  1878,  with  paralysis 
of  the  left  arm,  had  lost  two  brothers — one  of  some  cerebral  dis- 
order, and  the  other  of  convulsions,  each  at  the  age  of  one  year. 

Symjptoms. — These  often  set  in  suddenly,  the  paralj^sis  coming  on 
in  a  few  hours.  A  child  may  be  playing  about  in  his  usual  health, 
go  to  bed  apparently  in  all  respects  well,  and  wake  up  next  morn- 
ing paralyzed  in  one  limb  or  more;  most  frequently  in  the  lower 
extremities,  so  that  on  attempting  to  stand  or  support  himself  he 
falls.  The  paralysis,  or  inability  to  stand,  is  the  only  symptom  in 
many  cases.     There  is  no  pain  whatever.     A  male  child,  aged  four 

*  Clinical  Lecture  on  Cases  of  Acute  Atrophic  Paralysis  in  Infants  and  Adults,  by 
T.  Buzzard,  M.D.,  the  Lancet,  1880,  vol.  ii,  p.  925. 


INFANTILE    PARALYSIS.  649 

years,  of  pale  and  delicate  appearance,  came  under  my  notice  in 
September,  1875,  with  complete  paraplegia.  Two  months  before  I 
saw  him,  he  was  playing  on  a  lawn  one  evening  in  his  usual 
health.  ISText  morning  he  could  not  use  his  legs,  and  he  was  un- 
able to  do  so  for  some  months  afterwards.  The  muscles  of  the 
calf  became  flabby  and  the  joints  relaxed;  his  appetite  was  excel- 
lent, and  he  had  (as  is  most  usually  observed  in  these  cases)  perfect 
control  oyer  the  sphincters.  The  urine  was  healthy,  the  tempera- 
ture normal,  and  there  was  no  tenderness  in  any  part  of  the  spine. 
He  was  ordered  friction  with  bay  salt  for  the  limbs,  flannel  cloth- 
ing next  the  skin,  and  the  syrup  of  the  hypophosphite  of  iron 
twice  daily,  as  he  was  weak  and  pale.  A  fortnight  later  there 
was  some  improvement,  for  when  his  feet  were  allowed  to  touch 
the  ground  he  could  move  one  foot  in  advance  of  the  other.  He 
also  crawled  about  the  floor  with  greater  ease  than  at  first,  and 
did  not  allow  his  legs  to  remain  so  long  at  rest.  A  month  after- 
wards he  moved  his  legs  with  still  more  freedom  when  supported, 
with  his  feet  touching  the  ground,  and  he  had  more  confidence  in 
himself.  The  muscles  of  the  calf  in  both  legs  were  much  less 
firm  than  those  of  the  nates  and  thigh,  which  were  in  no  degree 
wasted  ;  the  loins  were  well  developed,  and  the  patient  sat  up 
fairly  well  in  a  chair.  The  spine  was  nowhere  prominent,  nor  was 
any  tenderness  felt  on  percussion.  He  could  move  the  left  leg 
with  the  greatest  ease  when  sitting  down,  pulling  it  up  rapidly 
under  him,  but  he  could  do  nothing  with  the  right  leg  in  the  way 
of  lifting  it  up  like  the  other,  though  he  felt  the  ground  with  it, 
and  when  the  sole  was  touched  with  a  pin,  or  tickled,  he  com- 
plained, but  not  the  least  reflex  action  was  induced.  The  right 
foot  was  colder  and  more  swollen  than  the  left.  Iron  and  strych- 
nia were  prescribed. 

In  1878  the  child  could  walk  when  taking  any  person's  hand, 
but  the  muscles  were  still  wasted  and  weak,  and  he  moved  along 
timidly  and  insecurely.     There  was  a  tendency  to  diarrhoea. 

In  some  cases  there  is  febrile  disturbance,  which  may  last  several 
days,  with  thirst,  loss  of  appetite,  headache,  screaming,  convul- 
sions, and  loss  of  consciousness.  These  symptoms  may  rapidly 
develop  themselves  after  the  paralysis  has  been  established.  In 
other  cases  again  there  w^ould  appear  to  be  no  fever. 

The  arms  may  be  alone  aftected,  but  more  commonly  the  legs, 
sometimes  one  arm  or  one  leg,  or  one  arm  and  leg  of  the  same  side^ 


650  DISEASES   OF   CHILDREjST. 

or  opposite  sides.  In  very  exceptional  cases  both  arms  and  botli 
legs  are  affected,  bat,  as  previously  stated,  the  right  leg  is  the  most 
frequent  seat  of  infantile  paralysis.  When  the  paralysis  occurs  in 
one  arm,  say  the  left,  the  patient  will  use  the  right  hand  to  eat  or 
drink,  and  make  no  use  of  the  left  whatever.  The  thumb  and 
fingers  may  be  widely  separate,  and  the  back  of  the  hand  when  ex- 
tended has  a  rather  concave  appearance.  The  hand  drops  at  the 
wrist  as  if  useless,  tbe  thumb  is  flexed  inwards  towards  .the  palm, 
and  the  phalangeal  articulations  are  all  loose.  On  attempting  to 
take  up  anything  the  child  will  slide  the  object  to  the  edge  of  the 
table  before  it  can  be  grasped.  The  hand  will  swell  when  cold 
and  look  bluish.  If  the  leg  of  the  same  side  is  also  affected,  so  as 
to  constitute  hemiplegia,  or  indeed  if  it  be  alone  affected,  the  child, 
even  with  assistance,  walks  unsteadily,  the  limb  being  moved  with 
less  freedom  than  the  sound  one.  He  turns  out  his  foot,  the 
ankle-joint  being  bent  inwards  at  the  same  time,  so  that  he  rests 
chiefly  on  the  inner  border  of  the  foot.  On  looking  upwards  the 
patient  is  afraid  to  venture  to  walk;  he  requires  to  watch  his  foot 
at  every  step. 

Considerable  wasting  in  the  muscles  of  the  gluteal  region  and 
thigh  may  often  be  observed.  In  some  cases  it  is  chiefly  noticea- 
ble in  the  gastrocnemius,  and  the  muscles  of  the  foot,  especially 
the  small  interossei.  The  affected  limb,  from  diminished  size  of 
the  bloodvessels,  generally  feels  much  colder  than  its  fellow,  and 
is  damp;  the  toes  too  present  a  bluish  aspect,  and  there  is  a  lia- 
bility to  cViilblains  (Buzzard,,  op.  cit.).  The  paralysis  is  attended 
with  flaccid  muscles,  and  signs  of  atrophy;  the  muscular  tissue 
undergoes  degeneration  or  absorption,  so  that  in  severe  cases  it  al- 
most entirely  disappears,  and  leaves  the  skin  in  close  contact  with 
the  bone.  The  ligaments  are  relaxed,  and  deformity  of  one  or 
both  feet  is  not  uncommon.  The  patella  tendon  reflex  is  absent 
in  the  affected  limb.  The  extensors  in  infantile  paralysis  are  more 
frequently  aftected  than  the  flexors,  and  as  a  result  of  this  the 
flexors  become  permanently  contracted.  Reflex  excitability  is 
soon  abolished,  and  the  muscles  do  not  contract  under  the  employ- 
ment of  faradization.  "  Many  of  the  muscles  paralyzed  lose  their 
faradaic  excitability  entirely  within  a  week,  and  rapidly  waste. 
But  although  they  fail  to  respond  to  the  strongest  induced  cur- 
rents they  react  to  slow  interruptions  of  the  constant  current  (re- 
action of  degeneration).     The  nerves  to  the  muscles,  on  the  other 


INFANTILE   PARALYSIS.  651 

hand,  lose  their  excitability  to  both  forms  of  electrical  excitation. 
Some,  again,  of  the  muscles  whose  faradaic  excitability  has  been 
lowered,  but  not  lost,  are  not  long  in  regaining  the  power  of  con- 
traction to  voluntary  impulses."*  In  mild  cases,  the  use  of  the 
battery  maintains  the  contractility  of  the  muscular  fibre  till  the 
fundamental  cause  of  the  disease  is  remedied,  thus  preventing 
permanent  and  irremediable  muscular  atrophy.  In  this  disease 
there  is  an  absence  of  pain,  and  a  freedom  from  irritation  of  the 
skin,  and  bedsores,  a  fact  which  distinguishes  it  strongly  from 
other  forms  of  paralysis. 

The  urine  often  contains  excess  of  phosphates.  These  were 
present  in  two  cases  under  my  care  at  the  same  time. 

A  remarkable  case  is  recorded  by  Dr.  Andrew  and  Dr.  Dyce 
Duckworth,  shows  that  a  form  of  "all  but  universal  paralysis" 
may  occur  in  childhood  from  exposure  to  heat,  and  be  followed 
by  complete  recovery.  The  patient  was  a  little  girl  two  and  a 
half  years  old.  There  was  almost  complete  loss  of  motor  power 
in  her  arras  and  legs,  and  ansesthia  of  the  affected  parts.  The 
muscles  were  soft,  wasted  and  flabby,  and  the  urine  and  faeces 
passed  involuntarily.  The  authors  considered  that  the  case  differed 
from  essential  infantile  paralysis  in  the  affection  of  the  sphincters, 
and  the  disturbance  of  sensation.  They  were  of  opinion 
that  the  symptoms  were  due  to  profound  nervous  exhaustion, 
affecting  the  spinal  marrow  as  well  as  the  muscles.  Steel,  cod- 
liver  oil,  and  belladonna  were  prescribed.  Faradization  was 
practiced  daily.     The  child  recovered  in  two  months. f 

Pathology. — The  disease  is  attributed  by  recent  observers  to 
inflammation  of  the  anterior  cornua  of  the  gray  matter  of  the 
spinal  cord,  whence  the  motor  roots  of  the  spinal  nerves  spring. 
The  large  cells  become  atrophied  and  at  length  disappear.  Accord- 
ing to  Charcot,  the  disease  begins  in  an  inflammation  of  the 
ganglionic  cells  of  the  anterior  cornua  of  the  gray  matter  of  the 
spinal  cord,  which  graduallj-  spreads  to  other  parts.  The  recovery 
of  the  limb  depends  upon  the  recovery  of  these  cells.  It  may 
affect  any  portion  of  the  cord,  cervical,  lumbar  or  dorsal,  but  the 
latter  is  the  most  rarely  involved.  Alluding  to  the  morbid  changes 
Dr.  Bristowe  says  "the  diseased  cornua  ultimately  shrink  in 
proportion  to  the  degree  and  duration  of  the  morbid  process.":]: 

*  Buzzard,  op.  cit.,  p.  925.  f  Med.-Chir.  Trans.,  1877,  p.  273. 

X  Principles  and  Practice  of  Medicine,  1877,  p.  981. 


652  DISEASES   OF    CHILDREN. 

The  muscles  do  not  shrink  in  all  cases.  "  Occasionally  they 
present  a  positive  increased  bulk,  owing  to  the  accumulation 
between  their  fibres  of  adipose  or  fibrous  tissue."*  Dr.  Althaus 
writes :  "  Infantile  paralysis  is  an  extremely  acute  myelitis  of 
moderate  intensity  which  is  either  diffuse,  or  occurs  in  circum- 
scribed areas,  and  affects  more  particularly  the  cervical  and 
lumbar  enlargements  of  the  cord."f  In  cases  that  terminate 
fatally  after  a  lapse  of  years,  the  anterior  cornua  are  found 
wasted  and  the  cells  disintegrated,  whilst  the  posterior  cornua 
are  healthy.  The  muscles  are  soft  and  atrophied,  more  or  less 
replaced  by  fat,  and  the  interstitial  tissue  hypertrophied  ;  the 
tendons  are  smaller,  the  bones  shorter,  and  the  medullary  canal  is 
enlarged  :}: 

*  Principles  and  Practice  of  Medicine,  1877,  p.  981. 

f  On  Infantile  Paralysis,  1878,  p.  15. 

X  Some  interesting  microscopical  specimens  of  tlie  spinal  cord  were  exhibited  before 
the  Pathological  Society  (February  8th,  1879).  The  spinal  cord  in  the  first  case  was 
from  a  child,  three  years  old,  who  had  suffered  from  infantile  paralysis  since  the  age 
of  fifteen  months.  There  was  a  history  of  a  blow  on  the  hip,  followed  in  three  days 
by  pain  in  the  left  leg,  paralysis,  and  feverishness.  Pain  lasted  ten  days,  and  then 
paralysis  remained.  The  child  died  of  bronchopneumonia.  The  muscles  of  the  left 
leg  Avere  pale  in  color,  and  soft  and  gelatinous  in  consistence.  The  lumbar  portion  of 
the  cord  was  diminished  in  size  on  the  left  side,  and  the  interior  roots  of  the  lumbar 
nerves  were  smaller.  Microscopically  there  was  almost  complete  absence  of  motor 
ganglion  cells  in  the  left  anterior  cornu  ;  the  substance  forming  the  basis  of  the  gray 
matter  had  lost  its  open  spongy  texture,  and  presented  a  uniform  feltlike  appearance. 
In  the  second  case  a  child,  two  and  a  half  years  old,  had  a  fall  which  did  not  appear  to 
hurt  it ;  thirteen  days  afterwards  the  left  arm  and  leg  became  paralyzed.  Tlien  both 
legs  lost  motion  and  sensation,  both  arms  were  powerless,  but  had  not  lost  sensation. 
The  evacuations  were  involuntary.  The  child  took  measles,  and  died  of  broncho- 
pneumonia nine  weeks  after  the  accident.  The  spinal  cord  was  much  diseased,  and 
the  gray  matter  was  thick,  and  there  were  patches  of  red  softening  in  the  anterior 
cornua  in  the  lumbar  regions.  Above  the  softened  parts  there  were  a  large  number  of 
leucocytes  in  the  perivascular  spaces.  There  were  no  ganglion  cells  on  the  left  side; 
exudation  corpuscles,  granular  bodies,  and  free  nuclei  took  their  place.  The  posterior 
horns  were  diseased,  but  more  on  the  right  side  than  the  left.  The  changes  were 
most  marked  in  the  cervical  portion  of  the  cord,  then  in  the  lumbar,  and  less  in  the 
dorsal ;  there  was  distinct  sclerosis  in  the  antero-lateral  columns  of  the  cord,  especially 
on  tlie  left  side.  In  the  third  case  the  child,  aged  three  and  a  half  years,  died  of 
scarlet  fever.  At  seventeen  months  old  slie  fell  ill  with  "relaxed  bowels,'' and  was 
unable  to  walk,  which  she  had  previously  done.  The  power  of  walking  soon  returned 
to  a  limited  extent.  Weakness  was  especially  noticeable  in  the  left  leg.  The  lumbar 
region  of  the  spinal  cord  was  found  on  section  to  be  smaller  on  the  left^han  on  the 
right  side,  and  it  was  most  marked  in  the  interior  cornu;  the  posterior  cornu  were 
equal  in  size  on  the  two  sides.  On  the  left  side  the  ganglion  cells  of  the  anterior 
cornu  had  nearly  disappeared ;  there  was  no  sclerosis  of  the  anterior  horns  or  of  the 
antero-lateral  columns. 


INFANTILE   PARALYSIS.  653 

Jreatment. — The  fact  that  several  distingnished  authorities  speak 
of  very  different  remedies  is  conchisive  that  no  specific  has  yet  been 
discovered ;  which  is  not  to  be  wondered  at  considering  the  ob- 
scure origin  of  the  disease.  In  the  early  stages,  where  there  are 
febrile  symptoms,  saline  aperients  and  medicines  which  control 
fever  are  necessary.  Two  or  three  leeches  to  the  spine,  and  counter- 
irritation  are  serviceable.  J^othing  can  be  done  without  the  most 
absolute  rest.  When  febrile  symptoms  have  departed,  we  must 
endeavor  to  restore  the  power  of  the  paralyzed  muscles. 

One  of  the  most  recent  writers  on  the  subject  (Dr.  Althaus) 
holding  the  theory  that  the  disease  commences  in  inflammation  of 
the  anterior  cornua,  strongly  recommends  the  subcutaneous  injec- 
tion of  ergotin.  He  proceeds  on  the  principle  that  this  alkaloid 
contracts  the  minute  bloodvessels  of  the  spinal  cord,  and  controls 
the  hyperpemia.  "I  used  a  solution  of  Bonjean's  ergotin  in  dis- 
tilled water,  which,  if  thoroughly  pure,  is  generally  not  irritating; 
and  the  dose  I  inject  is  one-fourth  of  a  grain  for  a  child  from  one 
or  two  years  of  age ;  one  third  of  a  grain  from  three  to  five  years  ; 
half  a  grain  for  children  from  five  to  ten  years  of  age;  and  a  grain 
for  patients  upwards  of  ten  years.  These  injections  must  be  re- 
peated according  to  the  symptoms  which  may  be  present,  either 
daily  or  twice  a  day.  Our  guide  of  action  in  the  matter  should 
be  the  thermometer  and  the  pupil.  In  severe  cases,  where  the 
thermometer  runs  up  to  103°  or  101°,  the  remedy  should  be  used 
more  freely  than  when  the  thermometer  shows  only  a  rise  of  one 
or  two  degrees.  The  fever  being  in  all  these  cases  a  secondary 
phenomenon,  consequent  upon  local  inflammation,  may  be  rapidly 
reduced  by  the  use  of  the  ergotin,  which  thus  proves  a  truly  an- 
tiphlogistic remedy ;  and  its  employment  should  be  continued 
until  the  temperature  has  fallen  to  the  normal  standard.  Where 
the  pupil  remains  much  contracted  after  the  use  of  the  remedy, 
some  time  may  be  allowed  to  elapse  before  it  is  again  injected,  but 
where  it  is  large,  the  dose  may  safely  be  increased  and  repeated. 
The  injection  is  not  painful  if  well  performed,  and  is  quite  as  easily 
done,  even  in  restless  children,  as  it  is  to  make  them  swallow  a 
dose  of  medicine.  The  place  of  injection  is  a  matter  of  indiflference. 
I  generally  inject  into  the  legs,  as  most  convenient."'^ 

I  have  had  no  experience  of  the  subcutaneous  injection  of 
strychnia,  recommended  by  Mr.  Barwell. 

*  On  Infantile  Paralysis,  1878,  p.  52. 


651  DISEASES   OF   CHILDREN. 

Belladonna  is  useful  by  controlling  a  liypersemic  condition  of 
the  cord,  and  its  membranes.  "  In  consequence  of  this  influence, 
it  diminishes  the  amount  of  blood  in  the  vertebral  canal,  and  in  so 
doing  produces  a  relative  diminution  of  the  vital  properties  of  the 
spinal  cord  and  its  nerves."*     Ergot  of  rje  has  a  similar  action. 

When  the  incipient  or  inflammatory  condition  is  reduced,  small 
doses  of  iodide  of  potassium  in  combination  with  bark  are  service- 
able, and  the  remedy  should  have  a  fair  trial.  It  checks  inflam- 
matory eftusion,  and  lessens  the  growth  of  connective  tissue. 

Where  the  disease  is  advanced  it  is  generally  admitted  that  no 
benefit  can  be  atibrded  except  by  galvanism  and  faradization.  A 
continuous  current,  from  ten  to  twenty  cells  of  a  Stohrer's  battery, 
to  the  spine  or  extremities,  sometimes  causes  no  muscular  response, 
and  the  cutaneous  sensibility  may  be  diminished.  This  treatment, 
however,  will  often  have  a  wonderful  efiiect  in  restoring  the  tone 
of  the  muscles  and  nerves.  In  those  cases  in  which  redness  of  the 
skin  is  excited,  and  the  feeling  of  pins  and  needles  is  produced,  re- 
covery may  be  generally  anticipated.  The  utility  of  the  faradiza- 
tion lies  in  its  maintaining  the  functional  activity,  and  with  it  the 
nutrition  of  the  muscles,  until  the  nervous  disease  is  recovered 
from.  When  it  is  employed  early,  before  degeneration  or  atrophy 
has  reached  any  important  stage,  the  disease  maybe  arrested,  and 
the  deformity  removed.  It  is  a  good  sign  when  the  paralyzed 
muscles  contract  and  become  warm  under  the  influence  of  faradiza- 
tion, and  the  child  shows  indications  of  pain  by  drawing  up  the 
leg  or  arm  as  the  case  may  be.  A  child  may  cry  from  the  first 
two  or  three  applications,  but  he  soon  gets  accustomed  to  the  pe- 
culiar sensation.  The  operation  should  be  continued  for  ten  min- 
utes daily. 

After  this  form  of  paralysis  has  lasted  some  time  and  the  mus- 
cles have  recovered  their  tone  and  strength,  the  patient  may  be 
unable  to  exercise  the  will,  so  as  to  bring  the  hand,  or  the  legs, 
properly  into  use.  This  complication  must  be  overcome  by  careful 
drilling.  "  When  any  amount  of  voluntary  power  has  been  re- 
stored by  electricity,  it  is  most  important  that  the  child  should  be 
encouraged  to  use  the  limb,  and  practice  various  movements. "f 

*  Paralysis  of  the  Lower  Extremities,  by  E.  Brown-S^quai-d,  M.D.,  F.  R.S.,  1861, 
p.  111. 

t  A  Handbook  of  Medical  and  Surgical  Electricity,  by  Herbert  Tibbits,  M.D.,  1877, 
p.  IGl. 


INFANTILE    PARALYSIS.  655 

Infantile  paralysis  is  a  very  chronic  and  tedious  disorder,  and  in 
some  instances  the  treatment  has  to  be  persevered  with  for  mouths 
or  even  years.  Muscles  which  seem  almost  hopelessly  wasted  and 
paralyzed,  sometimes  completely  recover  their  size  and  form  under 
a  steady  continuance  of  local  and  constitutional  measures. 

The  use  of  iron,  strychnia,  and  cod-liver  oil,  where  there  is 
general  ansemia,  and  an  absence  of  congestion  and  spinal  irrita- 
tion, ought  to  be  steadily  continued  for  weeks  or  months  together. 
It  is  an  excellent  plan  to  immerse  the  aftected  limb  in  hot  water 
for  ten  or  fifteen  minutes  daily,  before  shampooing  is  commenced, 
and  both  night  and  day,  to  maintain  the  warmth  of  the  aftected 
muscles  by  a  stocking  of  "  pure  spun  silk  "  or  "  chamois  leather," 
as  recommended  by  Dr.  Tibbits.  Cold  aft'usion  and  friction  of 
the  limbs  are  useful  in  restoring  the  tone  of  the  wasted  mus- 
cles. Mountain  air,  or  a  seaside  residence,  is  advisable  in  some 
cases. 

The  deformities  that  result  from  infantile  paralysis  will  require 
surgical  treatment. 

Duchenne's  Paralysis  {yseudo-hypertrophic  muscular  'paralysis). — 
This  disease  is  now  well  known  to  the  student  of  medical  litera- 
ture, from  the  researches  of  the  late  Dr.  Duchenne,  of  Boulogne, 
whose  name  is,  at  least  at  the  present  time,  always  associated 
with  it.  Since  that  physician  and  later  observers  turned  the 
attention  of  the  profession  to  the  complaint,  it  has  been  found  to 
be  less  rare  than  w^as  at  first  supposed,  Butliu  had  the  opportu- 
nity of  making  observations  on  four  cases,  all  under  treatment 
within  the  same  year  at  the  Children's  Hospital,  Ormond  Street. 
The  disease  is  most  frequent  among  boys.  Of  twenty-three  cases 
mentioned  by  Dr.  Gowers,  eighteen  occurred  in  boys. 

It  is  a  rare  form  of  paralysis  accompanied  by  enlargement  or 
hypertrophy  of  certain  muscles.  It  may  occur  in  children  who 
are  born  healthy  and  vigorous,  and  who  have  passed  through  the 
period  of  dentition  well.  The  majority  of  cases  begin  about  the 
sixth  year,  and  death  occurs  between  14  and  18.  The  rich  are 
more  prone  to  sufter  than  the  poor.  It  w^ould  also  seem  to  come 
on  after  any  severe  illness,  as  measles.  The  disease  is  slow  and 
chronic,  and  unattended  by  fever,  l^o  definite  cause  has  ever 
been  assigned,  but  authorities  generally  agree  that  it  is  most 
frequent  in  dull  and  idiotic  children.     Six  cases  are  mentioned  as 


656  DISEASES   OF   CHILDEElSr. 

having  occurred  in  the  same  family,  and  in  another  instance  eight 
brothers  died  of  the  disease.* 

Symptoms. — These  are,  first  those-of  weakness  in  the  lower  limbs, 
and  finally  loss  of  reflex  excitability.  If  the  child  is  old  enough 
to  walk,  he  moves  along  with  a  shuffling  gait,  placing  his  feet 
timidly  and  cautiously  on  the  ground,  lie  sways  his  body  from 
side  to  side,  and  swings  his  arms  at  every  step  he  takes.  The 
belly  is  prominent  or  arched  forward,  the  shoulders  are  thrown 
back,  and  there  is  a  curve  along  the  spine  (lordosis).  He  is  apt 
to  tumble  down  if  he  meets  with  any  impediment  in  his  way,  and 
cannot  get  up  again  without  assistance.  He  stands  with  his  feet 
apart  to  balance  himself,  with  the  toes  averted.  In  attempting 
to  rise  from  the  ground,  the  movements  are  very  peculiar ;  the 
patient  bends  one  knee,  first  placing  his  hands  on  it  or  some 
object  near  by  for  support,  he  then  bends  the  other  knee  into  the 
kneeling  position,  and  so  grasping  his  thighs  from  below  upwards, 
gradually  raises  his  shoulders  and  body  to  an  upright  position, 
proceeding  in  a  very  cautious  and  gradual  manner,  as  if  in  fear  of 
falling.  This  peculiar  action  has  been  considered  pathognomonic. 
"  Attention  was  called  to  it  by  Duchenne,  and  I  have  never  seen 
it  absent  in  a  case  so  long  as  the  j)atient  possessed  the  necessary 
muscular  power.  I  have  never  seen  it  in  any  other  disease,  and 
every  doubtful  case  in  which  it  was  present  ultimately  proved  to 
be  an  example  of  the  aflection.  Its  diagnostic  importance  is  thus 
very  great. "f 

The  disease  first  shows  itself  by  the  child  being  quite  unable  to 
walk  when  old  enouo-h  to  be2:in  to  do  so,  or  if  it  has  reached  the 
age  at  which  it  can  stand  by  itself,  or  walk,  or  run,  it  becomes 
very  weak  on  its  legs.  This  weakness  continues  for  many  months, 
progressing  slowly,  when  the  careful  medical  attendant,  on  exam- 
ining the  patient  stripped,  will  at  once  recognize  the  disease  if  he 
finds  that,  after  months  of  muscular  weakness,  the  muscles  of  the 
leg  have  become  larger  and  not  smaller.  In  a  few  more  months 
the  hypertrophy  extends  to  the  buttocks,  or  even  to  the  loins,  the 
weakness  increasing  rapidly.  The  great  firmness  of  the  aflfected 
muscles  when  set  into  action  would  puzzle  the  uninitiated  as  it 
resembles  what  is  seen  in  muscles  hypertrophied  by  healthy  exer- 
cise. 

*  Pseudo-hypertrophic  Paralysis,  by  W.  E.  Gowers,  M.D.,  1879,  p.  8. 

f  Pseudo-hypertrophic  Muscular  Paralysis,  by  W.  R.  Gowers,  M.D.,  1879,  p.  4. 


INFANTILE    PARALYSIS.  657 

This  hjpertropliic  stage  lasts  several  years,  and  is  followed  by 
gradual  and  complete  paralysis  ;  the  unaffected  muscles  lose  motor 
power;  those  involved  in  the  characteristic  enlargement  all  dimin- 
ish in  size.  The  patient,  now  perhaps  grown  out  of  childhood, 
ultimately  dies  through  falling  a  prey  to  some  visceral  affection, 
as  is  the  case  with  most  patients  attacked  by  the  other  rarer  and 
slower  forms  of  paralysis. 

Pathology. — In  this  peculiar  form  of  paralysis,  the  muscles  of 
the  calf  of  the  leg  become  enlarged  and  overgrown,  and  present  a 
remarkable  contrast  to  the  muscles  of  the  thigh  and  other  parts 
of  the  body.  In  one  case  the  gastrocnemii  were  abnormallj^  firm 
when  at  rest,  and  during  contraction,  hard  and  knotted  as  the 
biceps  of  a  blacksmith.*  Dr.  Gowers  found  that  on  cutting  into 
the  gastrocnemius  in  one  instance,  it  presented  the  appearance  of 
a  fatty  tumor.  It  was  a  mass  of  greasy  fat  without  any  muscular 
redness. t  The  microscope  reveals  a  degeneration  of  the  muscular 
fibres,  both  in  size  and  number,  and  a  great  overgrowth  of  the 
connective  tissue  between  the  bundles  of  fibres ;  fat  is  also  deposited 
freely  over  the  affected  part  of  the  muscle,  but  the  fibrous  hyper- 
plasia is  the  primary  morbid  change. 

In  one  case  related  by  Dr.  Ord,  there  was  increased  temperature 
in  the  affected  legs,  compared  with  the  thighs,  of  from  1.8°  to 
3.9°.:|:  In  another  case,  also  described  by  him,  the  thighs  were 
warmer  than  the  calves. § 

Prognosis. — This  is  extremely  grave.  The  patient  may  possibly 
recover  if  the  disease  should  become  stationary,  but  it  generally 
extends  upwards,  and  the  functions  of  deglutition  and  respiration 
becoming  involved,  death  takes  place  from  exhaustion  or  asphyxia. 
The  fatal  result  is  not  due  to  the  disease  itself,  but,  according  to 
Dr.  Gowers,  to  some  intercurrent  maladj^  "  The  weakness  and 
wasting  of  the  thoracic  muscles,  for  instance,  gradually  lessen  the 
respiratory  power.  The  patient  is  thereby  weakened ,  and  is  rendered 
an  easy  prey  for  the  maladies  which  lie  in  wait  for  the  infirm. 
The  most  common  cause  of  death,  indeed,  is  the  direct  interference 
with  the  action  of  the  lungs.  As  the  patient  becomes  weaker, 
bronchial  rales  are  heard  through  the  chest,  dyspncea  comes  on, 
and  is  rather  increased  than  lessened  by  the  patient's  feeble  at- 

*  Med.-Chir.  Trans ,  1877,  p.  21,  Pseiido-hypertrophic  Paralysis,  by  W.  M.  Ord, 
M.D. 

t  Op.  cit.,  p.  40.  %  Med.-Chir.  Trans.,  1874,  p.  16.  §  Ibid.,  1877,  p.  19.. 

42 


658  DISEASES    OF    CHILDEEX. 

tempts  to  cougli.  Pyrexia  may  be  developed,  and  the  patient  dies 
with  the  signs  of  a  chronic  bronchopneumonia,  which  has  in  many 
cases  been  found  after  death."* 

Treatmerd. — This  is  in  the  highest  degree  unsatisfactory,  and 
must  be  chiefly  symptomatic  or  palliative  during  the  later  stages. 
When  the  disease  has  lasted  only  a  short  time,  it  may  sometimes 
be  retarded  or  arrested  by  friction,  galvanism,  and  muscular  exer- 
cises. Arsenic  and  phosphorus  are  among  the  best  remedial 
agents ;  cod-liver  oil  is  preferable  to  either. 

Neuralgia  is  rare  in  children,  but  the  practitioner  should  be 
aware  of  its  occasional  occurrence.  I  have  met  with  a  few  cases 
of  facial  neuralgia  in  young  children,  apparently  independent  of 
gastric  disturbance.  One,  a  most  severe  case,  in  a  girl  nine  years 
of  age,  which  yielded  to  good  food  and  quinine.  I  am  assured  by 
the  mother  that  her  child,  four  years  of  age,  suffered  from  parox- 
ysms of  severe  pain  in  the  right  leg  and  heel,  which  medical  men 
thought  was  neuralgic.  Genuine  neuralgic,  or  one-sided  headache 
(supraorbital  neuralgia)  is  equally  rare  in  children;  but  it  is  oc- 
casionally met  with  in  anaemic  subjects  if  badly  fed  or  overworked 
at  school. t  Xeuralgia  sometimes  attacks  the  intercostal  nerves, 
producing  pleurodynia,  or  the  brachial  plexus,  causing  brachial 
neuralgia.  Attacks  of  pain  over  the  cardiac  region  in  delicate 
children  are  often  of  neuralgic  origin. 


CHAPTER  XLAail. 

RHEUMATISM. 

Df^niti(m — Symptoms — Occasional  high  temperature — Pathology — Causes — Prognosis  and 
consequences.  Teeatjient  :  Importance  of  rest — Free  purgation  at  the  early  stages — 
Sedatives  to  relieve  pain — Alkalies,  ichen  to  be  employed— Salicin  and  its  compounds — 
Their  action  in  reducing  temperature  and  shortening  the  seizure — Efficacy  of  the  cold 
bath  in  hyperpyrexia — Lotions — Small  blisters  to  the  joints — Bark — Preparations  of 
iron — Cod-liver  oil  and  warm  clothing  in  the  convalescent  stage. 

GorT :  Its  occasional  occurrence  in  children. 

Acute  rheumatism  is  a  most  painful  disease  which  attacks  the 
larger  and  smaller  joints,  but  especially  the  former  ;  it  is  accom- 
panied with  fever,  and  is  prone  to  involve  the  fibro-serous  struc- 

*  Gowers,  op.  cit.,  p.  40.        f  Headaches,  by  \\.  H.  Day,  M.D.,  3d  edit.,  p.  306. 


ACUTE    RHEUMATISM.  659 

tures  of  tlie  heart  and  pericardium.  Rheumatism  is  not  so  frequent 
in  childhood  as  in  youth  and  adult  life.*  The  youngest  child  I 
have  seen  with  rheumatic  fever  was  nearly  six  years  old.  Yogel 
has  met  with  a  case  in  a  child  one  year  and  nine  months  old,  who 
succumbed  to  disease  of  the  heart  after  three  months. f  It  closely 
resembles  the  acute  rheumatism  of  adults,  but  it  is  usually  less 
severe  and  protracted.  It  is  essentially  a  disease  of  the  joints  and 
of  the  heart,  the  structure  of  its  lining  membranes  being,  as  Mr. 
Hilton  points  out,  like  that  of  a  joint, — fibro-serous. 

Symptoms. — These  begin  not  unlike  a  common  cold,  with  pain 
in  the  back  and  limbs,  followed  by  shivering  and  feverishness. 
Aftec  the  lapse  of  a  day  or  two,  or  it  may  be  a  week,  one  or  more 
of  the  larger  joints  become  swollen  and  painful,  the  surface  is 
hot  and  inflamed,  and  the  tenderness  so  great  that  the  least  move- 
ment of  the  bed  will  aggravate  the  suffering.  The  pain  in  some 
cases  is  most  erratic,  it  may  begin  in  the  side,  and  the  next  day 
attack  the  knees,  ankles,  shoulders,  or  fingers  ;  one  day  it  may  be 
confined  to  the  feet  or  knees,  and  the  next  day  it  may  seize  nearly 
all  the  joints,  lingering  for  an  uncertain  time  in  one  or  more;  and 
the  child  suffers  from  restlessness  and  sleeplessness,  or  delirium  at 
night.  It  should  be  borne  in  mind  that  delirium  in  the  course  of 
rheumatic  fever  is  usually  the  consequence  of  exhaustion,  and  if 
the  pulse  is  at  all  unsteady,  and  the  skin  freely  sweating,  stimu- 
lants may  be  needed.  There  is  loss  of  appetite  and  thirst ;  the 
neck  is  so  stiff"  in  some  cases  from  implication  of  the  cervical 
muscles,  that  the  child  cannot  bear  the  head  elevated  to  swallow 
food,  the  slightest  movement  increasing  the  torture.  Even  inspira- 
tion is  painful  if  the  pectoral  muscles  are  implicated. 

The  temperature  varies  from  101°  to  103°,  or  more,  and  there 
are  few  diseases  in  which  it  may  run  so  high.  Dr.  H.  Weber  has 
recorded  an  interesting  case  where  the  temperature  reached  108.2°, 
with  delirium,  and  other  brain  symptoms,  in  a  lad  16  years  of 
age.  The  patient  recovered  under  cold  baths  and  cold  affusion.:}: 
The  pulse  is  full  and  soft ;  at  times  hard  and  bounding,  from  100 
to  120 ;  the  tongue  is  coated  with  a  thick  white  fur,  the  bowels 

*  "  Of  the  ages  of  patients  affected  with  acute  rheumatism,  out  of  159  cases  ad- 
mitted into  the  London  Hospital,  two  were  between  5-10,  nineteen  between  10-15, 
seventy-seven  between  15-25,  forty-three  between  25-35,  twelve  between  35-45,  and 
six  between  45-55." — Report  of  the  Medical  Registrar  for  1876,  by  G.  E.  Herman, 
M.E.C.P. 

t  Diseases  of  Children,  1874,  p.  232,  %  Clin.  Trans.,  1872,  p.  136. 


660  DISEASES   OF   CHILDEEN. 

are  costive,  and  the  skin  is  bathed  in  perspiration  of  a  sour  and 
sickly  smelling  character,  which  brings  no  relief  to  the  pain  and 
suffering.  Everything  about  the  body  of  the  patient  is  acid,  the 
saliva  is  acid,  the  sweat  from  all  parts  of  the  body  is  acid,  and 
even  the  breath  has  an  acid  odor.  The  urine  is  high-colored, 
intensely  acid,  and  scanty.  On  standing  in  a  deep  vessel  for  a 
short  time  it  throws  down  a  copious  pink  deposit  of  urate  of 
ammonia.  The  chlorides  are  deficient.  It  is  occasionally  albumin- 
ous both  in  adults  and  children.  This  arises  from  congestion  and 
renal  irritation,  due  to  the  rheumatic  poison,  or  perhaps  the  high 
temperature;  just  in  the  same  way  as  it  often  occurs  in  some 
other  acute  diseases  marked  by  pyrexia,  as  scarlatina,  measles, 
and  bronchitis.  It  must  not  be  inferred  in  such  cases  that  the 
kidneys  are  really  unsound.  The  high  specific  gravity  is  a  proof 
of  temporary  congestion,  caused  by  the  increased  work  thrown 
upon  the  kidneys. 

As  regards  the  jpathology  of  the  disease,  it  appears  to  depend  on 
an  excess  of  lactic  acid  in  the  blood.  Dr.  Balthazar  Foster  has 
recorded  several  cases  where  the  symptoms  of  acute  rheumatism 
were  produced  by  lactic  acid,  given  for  the  treatment  of  diabetes.* 
If  blood  be  drawn  from  a  vein  it  is  found  to  be  both  buffed  and 
cupped,  the  fibrin  being  in  excess. 

The  date  when  improvement  commences  is  uncertain.  It  may 
commence  in  a  few  days  after  the  disease  has  begun,  and  the  du- 
ration of  it  is  certainly  shorter  than  it  is  in  adults,  but  it  may  be 
delayed  longer,  and  last  from  a  month  to  six  weeks.  The  symp- 
toms that  indicate  the  decline  of  the  disorder  are  an  abatement  of 
the  pain,  calm  sleep  at  night,  and  a  free  and  copious  discharge  of 
urine,  which  throws  down  a  deposit  of  lithates. 

Relapses  are  common  ;  a  little  boy,  aged  eight  years,  was  ad- 
mitted on  five  separate  occasions  into  the  Samaritan  Hospital  with 
acute  articular  rheumatism,  and  an  aggravation  of  mitral  mis- 
chief consequent  on  the  first  attack. 

In  many  cases  the  heart  becomes  involved  during  the  progress 
of  the  articular  inflammation,  and  the  younger  the  patient  the 
more  likely  is  this  to  occur.  The  symptoms  which  indicate  this 
serious  complication  are  not  always  obvious.  The  cardiac  affec- 
tion may  steal  on  imperceptibly,  and  be  overlooked  till  the  joint 
affection  subsides,  and  there  is  an  abatement  of  the  pain.     A 

*  Brit.  Med.  Journal,  Dec.  23,  1871. 


ACUTE   RHEUMATISM.  661 

moderate  des-ree  of  febrile  disturbance,  and  a  slio;ht  affection  of 
the  joints,  afford  no  guarantee  that  the  heart  will  not  become  im- 
plicated in  the  course  of  the  rheumatic  affection ;  indeed,  it  may 
be  the  first  organ  seized  upon  in  these  young  subjects,  before  there 
is  any  pain  or  swelling  "in  the  joints.  So  much  is  this  the  case, 
that  the  heart  affection  may  be  the  first  symptom  to  raise  sus- 
picion of  the  nature  of  the  malady,  and  it  is,  therefore,  wise  in  all 
cases  of  obscure  febrile  attacks  in  young  children,  to  auscultate 
the  heart  carefully  and  frequently  lest  the  disease  be  overlooked. 
But,  as  a  rule,  if  endocarditis  or  pericarditis  is  about  to  happen, 
there  will  be  restlessness,  or  even  convulsions,  dyspnoea,  pain  in 
the  cardiac  region,  oppression,  and  inability  to  lie  on  the  left  side.* 
In  other  cases,  bronchitis,  pneumonia,  or  pleurisy  supervene,  and 
even  inflammation  of  the  brain. 

Causes. — The  disease  generally  follows  exposure  to  cold  and  wet 
in  delicate  constitutions,  especially  if  there  is  insufiicient  clothing. 
A  previous  attack  renders  a  child  susceptible  to  a  return.  The 
rheumatic  diathesis,  too,  is  very  marked  in  some  families.  "  Of 
twelve  children  of  a  mother  who  had  suffered  from  acute  rheuma- 
tism and  heart  complication,  eleven  had  the  disease  before  they 
were  20  years  of  age.f  This  is  probably  as  remarkable  a  record 
as  could  be  found  in  the  history  of  the  disease.  Acute  rheuma- 
tism sometimes  follows  scarlatina. 

Prognosis  and  Consequences. — If  the  disease  is  confined  to  the 
joints,  and  the  urine  throws  down  a  copious  lateritious  sediment, 
with  an  abundance  of  uric  acid,  the  case  is  favorable  ;  but  if  the 
articular  inflammation  suddenly  becomes  less,  and  inflammation  is 
lighted  up  in  the  heart  or  brain,  then  the  prognosis  is  less  favor- 
able. The  disease  rarely  terminates  fatally,  if  uncomplicated,  but 
is  apt  to  lead  to  valvular  disease  of  the  heart  (especially  mitral 
mischief),  to  be  followed  by  a  chronic  form  of  the  complaint.  As 
relapses  are  very  common  in  rheumatic  fever,  the  treatment  should 
not  be  abandoned  too  soon.  Injudicious  feeding,  and  especially 
overindulgence  in  animal  food,  frequently  invite  a  return.  The 
younger  the  patient  the  greater  the  liability  to  heart  affection. 

Treatment. — The  most  absolute  rest  should  be  maintained,  for 
any  movement  not  only  amounts  to  torture,  but  relapse  is  less 
likely  to  ensue  when  patients  are  kept  long  enough  in  bed,  and  on 

*  See  Pericarditis  in  Chap.  XLI,  p.  532,  On  Diseases  of  the  Heart, 
t  Steiner's  Diseases  of  Children,  by  Lawson  Tait,  1874,  p.  336. 


662  DISEASES   OF   CHILDREN. 

a  liquid  diet.  "  Extreme  repose  is  worth  all  the  other  means  of 
relief  put  together."*  So  that  the  earlier  the  child  suffering  from 
the  disease  comes  under  treatment  the  shorter  is  the  probable 
duration  of  the  complaint.  The  sheets  to  be  removed,  and  the 
patient  clothed  in  flannel,  whilst  the  diet  should  be  a  fluid  one, 
consisting  of  milk,  light  broths,  and  arrowroot. 

The  chief  object  at  the  beginning  of  treatment,  is  to  encourage 
a  free  action  of  the  skin  and  kidneys,  to  unload  the  buwels  by  a 
freely  acting  purge,  in  order  to  drain  the  mucous  membrane  eflect- 
ually.  For  this  purpose  a  dose  of  calomel,  followed  by  an  aperient 
mixture  (Form.  8-41),  or  compound  jalap  powder,  or  compound 
liquorice  powder  (Ger.),  will  be  necessary.  So  long  as  there  is 
high  sthenic  action,  the  bowels  must  be  kept  open  ;  yet,  active 
purging  necessarily  involves  movement.  The  necessity  for  purg- 
ing is  often  very  obvious,  whilst  its  disadvantages  are  equally  so, 
and  therefore  it  becomes  a  difficult  question  in  practice  to  decide 
whether  the  patient  should  be  purged  or  not.  If  there  are  pink 
lithates  in  the  urine,  a  cojdIous  supply  of  potash  is  needed.  If 
there  is  severe  pain,  opium,  or  some  preparation  of  it,  as  Dover's 
powder,  ought  to  be  given  freely  to  relieve  it ;  either  alone,  or  with 
alkalies  in  large  doses. f  For  the  relief  of  thirst,  barley-water 
flavored  with  lemon,  seltzer- water,  toast  and  water,  or  plain  water 
are  indicated. 

There  is  much  to  recommend  the  view  that,  when  the  urine  is 
alkaline,  the  heart  is  generally  safe.  The  late  Dr.  Fuller  said,  "  In 
no  single  instance  has  a  patient  of  mine  been  attacked  with  endo- 
carditis or  pericarditis  after  the  urine  has  shown  an  alkaline  re- 
action.":j:  This  may  be  effected  in  the  space  of  twenty-four  hours, 
if  large  doses  are  given  at  intervals  of  three  hours  during  that 

*  On  the  Treatment  of  Acute  Eheumatism,  by  T.  K.  Chambers,  M.D.,  The  Lancet, 
vol.  ii,  p.  199,  1862. 
t  Formula  85 : 

R.  Pulv  ipecac.  CO., grs.  iij. — M. 

To  be  taken  in  a  little  water-arrowroot  and  repeated  when  necessary. 
Formula  86 : 

R.  Potass,  bicarb., ^ij 

Potass,  nitrat.,      .         .         .         .         •         .         -By 

Tinct.  opii, ''Kxvj 

Syr.  limonum, ^ss. 

Aqnam  ad    .......         .     ^iv. — M. 

A  dessertspoonful  every  three  or  four  hours.     For  a  child  six  years  of  age. 
J  On  Gout,  Rheumatism,  Rheumatic  Gout,  and  Sciatica,  The  Lancet,  vol.  ii,  1862. 


ACUTE   RHEUMATISM.  663 

time.  Alkalies  appear  to  possess  the  power  of  keeping  the  fibrin 
in  a  soluble  condition,  and  so  preventing  its  deposition  on  the 
valves  of  the  heart,  whilst  they  tend  at  the  same  time  to  purify 
the  blood  by  increasing  the  action  of  the  kidneys.  According  to 
Dr.  Eichardson,  carbonate  of  ammonia  possesses  this  power  of  main- 
taining a  fluid  condition  of  the  blood  in  a  greater  degree,  and  al- 
though it  has  not  the  same  influence  over  the  rheumatic  affection 
as  potash,  it  may  sometimes  be  combined  with  it  advantageously 
when  there  is  depression.*  Antimony  acts  in  a  similar  manner, 
and  likewise  controls  the  force  of  the  circulation.  "  Still,  there 
are  a  certain  number  of  instances  where  true  rheumatic  inflam 
mation  is  very  obstinate,  and  does  not  yield  to  the  alkaline  method. 
And  in  these  you  will  find  the  periosteum  and  perichondrium  af- 
fected. When,  then,  after  five  or  six  days  the  patient  is  no  better, 
or  but  little  better,  I  add  iodide  of  potassium  to  the  potash,  and 
in  a  few  days  more  continue  it  alone  during  the  convalescence. 
And,  of  course,  if  I  am  enabled  to  make  out  this  condition  of  peri- 
osteum at  the  first  visit,  I  begin  such  treatment  straightway. "f 

During  the  last  few  years  the  introduction  of  salicin  and  its 
compounds  into  practice  has  found  some  warm  advocates.  These 
preparations  possess  the  power  of  reducing  the  high  temperature 
of  acute  rheumatism,  and  the  pyrexia  of  some  other  diseases. 
Salicin,  salicylic  acid,  and  salicylate  of  soda,  have  a  very  decided 
eftect  in  shortening  the  duration  of  the  pain  and  fever,  and  in  re- 
ducing the  percentage  of  heart  disease;  but  of  all  the  three  reme- 
dies employed,  the  last  is  perhaps  the  best.:}: 

Salicin  was  first  introduced  by  Dr.  Maclagan,  of  Dundee.  He 
recommends  that  it  be  given  in  large  doses,  twenty  to  thirty 
grains  every  two  hours  for  an  adult  till  the  pain  abates.  Of  course 
smaller  doses  will  be  required  for  children.     "  We  are  indebted  to 

*  "  When  fibrin  is  as  yet  in  solution  in  the  blood,  it  is  the  easiest  matter  in  the  world 
to  keep  it  fluid  ;  the  addition  of  a  very  small  quantity  of  alkali,  say  two  parts  of  alkali 
to  a  thousand  of  blood,  is  sufficient  for  this  purpose.  But,  when  fibrin  has  separated, 
its  resolution  is  a  difficult  matter." — On  Fibrinous  Deposition  in  the  Heart,  1862,  p.  40. 

f  On  the  Treatment  of  Acute  Rheumatism,  by  T.  K.  Chambers,  M.D.,  The  Lancet, 
vol.  ii,  p.  200,  1862. 

X  Of  89  cases  of  acute  rheumatism,  treated  by  salicin  and  its  compounds  in  the 
London  Hospital,  in  1876,  the  average  stay  in  the  hospital  was  36.1  days,  and  those 
treated  otherwise  41.8  days.  The  symptoms  yielded  sooner  under  the  first  mode  of 
treatment ;  the  duration  of  the  pain  and  pyrexia  was  shorter,  and  there  was  a  less  lia- 
bility to  heart  disease.     Relapses,  however,  were  rather  more  common. 


Q64:  DISEASES   OF   CHILDREN. 

C.  W.  Brown,  late  House  Physician  at  the  Boston  City  Hospital, 
for  the  most  valuable  and  extensive  investigation  into  the  action 
of  salicylic  acid  on  rheumatic  fever.  He  records  160  cases,  taken 
indifterently,  the  patients  being  of  each  sex,  and  of  all  ages  be- 
tween 13  and  61.  The  drug  gave  considerable  relief  from  pain  on 
an  average  in  1.46  days,  and  complete  relief  in  2.8  days.  The 
average  time  of  treatment  was  6  days,  and  the  average  number  of 
days  in  hospital  was  18  days."* 

All  authorities  agree  that  salicylic  acid  has  a  remarkable  effect 
in  reducing  the  temperature  of  rheumatic  fever.  This  it  does  ef- 
fectually and  rapidly,  but  relapses,  as  vomiting,  vertigo,  profuse 
sweating,  and  collapse  do  sometimes  attend  its  employment,  and, 
therefore,  it  is  well  to  be  prepared  for  these  symptoms.  Dr.  Whip- 
ham,  of  St.  George's  Hospital,  and  Mr,  Poole  Collyns,  resident 
Medical  officer  at  the  Atkinson  Morley  Hospital,  Wimbledon, 
treated  at  the  latter  institution  twelve  cases  of  acute  rheumatism 
with  salicin,  salicylic  acid,  and  its  salts,  with  a  view  of  arresting 
the  disease  at  its  onset.  In  some  of  the  cases  the  disease  yielded 
after  a  few  doses,  and  in  others  the  pains  were  relieved  in  a  few 
days.  In  two  of  the  cases,  attended  by  a  pericardial  friction- 
sound,  the  sj^mptoms  passed  away  in  four  days  after  commencing 
the  treatment. f  Dr.  Greenhow  considers  that  salicin  and  salicy- 
late of  soda  do  not  prevent  complications  arising  in  the  course  of 
rheumatic  fever,  which  are  equally  frequent  during  this  treat- 
ment ;  the  patient  is  neither  better  nor  worse,  nor  is  he  disabled 
for  a  longer  or  shorter  time  after  it.  Anaemia  appears  to  follow 
the  salicylate  of  soda  treatment,  and  health  and  strength  are 
slowly  regained.  The  pain  and  distress  of  the  patients  are  les- 
sened by  both  these  agents,  but  the  duration  of  the  illness  is  not 
shortened.  Dr.  Greenhow  expresses  his  conviction  that  the  weaken- 
ing of  the  first  sound  of  the  heart  indicates  an  influence  upon  the 
muscular  structure  of  that  organ.  He  prefers  blisters  in  the 
vicinity  of  the  painful  joints  as  affording  speedy  relief,  and  not 
producing  so  much  subsequent  debility. :j: 

In  the  selection  of  salicin,  salicylic  acid,  and  its  salts,  some  diflter- 
ence  of  opinion  prevails  amongst  medical  men,  as  to  which  is  the 

*  Handbook  of  Therapeutics,  by  S.  Einger,  M.D.,  8th  edit.,  p  597. 
t  On  the  Effect  of  Ralicin,  .Salicylic  Acid,  and  its  Salts,  in  the  early  manifestations 
of  Rheumatism,  St.  George's  IIosp.  Rep.,  1874-76,  p.  173. 
X  Clin.  Soc,  vol.  xiii,  p.  2i4-2G2. 


ACUTE    RHEUMATISM.  665 

best  of  these  remedies.  Salicin  is  more  soluble  than  salicylic  acid, 
it  is  less  likely  to  cause  sickness,  and  is  not  so  unpleasant  to  the 
palate ;  it  may  be  given  with  a  little  syrup  and  aromatic  water.* 
Salicylic  acid  may  be  combined  with  the  liquor  ammonise  acetatis,t 
or  the  bicarbonate  of  potash.:}:  Salicylate  of  soda  may  be  given 
in  plain  water,  with  a  little  simple  syrup.g  It  is  now  generally 
admitted  that  the  last  is  the  best  form  of  administration,  owing 
to  its  solubility  and  the  rapid  manner  in  which  it  is  absorbed. 
Respecting  the  use  of  salicylate  of  soda.  Dr.  Cavafy  says :  "  With 
regard  to  dose  and  mode  of  administration,  I  am  convinced  that 
the  best  plan  is  to  thoroughly  saturate  the  patient  with  the 
remedy  at  the  commencement,  and  then  to  gradually  diminish  the 
dose  and  lengthen  the  interval  after  a  distinct  result  has  been  pro- 
duced. Relapses  are  best  avoided  by  continuing  the  drug  in  small 
doses  during  convalescence,  in  just  sufficient  quantity  to  cause  the 
urine  to  give  a  violet  tint  with  perchloride  of  iron."||  Dr.  S.  J. 
Sharkey  says  "  that  the  presence  of  albumen  in  the  urine  does 
not  contraindicate  the  exhibition  of  salicylate  of  soda,'"^  and  Dr. 
Theodore  Ackland  "  observes  that  of  five  cases  of  acute   rheu- 

*  Formula  87 : 

R.  Salicin, Qij 

Syr.  aurant., ^^s- 

Aquam  cinnamomi  ad      . §iv. — M. 

A  dessertspoonful  to  be  taken  every  four  hours.     For  children  six  years  of  age. 
t  Formula  88 : 

R.  Liq.  amm.  acet.,       ........     .^ss. 

Acid  salicylic, 9ij 

Syr.  aurant., ^iij 

Aquam  ad         ........         .     §iv. — M. 

A  dessertspoonful  every  four  hours.     For  children  six  years  of  age. 
X  Formula  89 :  ■ 

B.  Potass,  bicarb. 

Acid,  salicylic,  aa ^ij 

Syrupi, 3iij 

Aquam  anethi  ad 5iv. — M. 

A  dessertspoonful  every  four  hours.     For  children  six  years  of  age. 
§  Formula  90 : 

R.  Sodse  salicylat.,         .         . ^ij 

Syrupi, 3iij 

Aquam  ad giv. — M. 

A  dessertspoonful  every  four  hours.     For  children  six  years  of  age. 
II  Eheumatism  treated  by  Salicylate  of  Soda,  St.  George's  Hosp.  Eeports,  1874-76, 
p.  199. 

^  St.  Thomas's  Hosp.  Eeports,  1877,  p.  81, 


G66  DISEASES   OF    CHILDREN. 

matism  witli  albuminuria,  the  albumen  disappeared  in  each  case 
while  the  drug  was  being  administered."'^"  Nervous  symptoms, 
in  the  form  of  headache,  deafness,  singing  in  the  ears,  and 
occasional  delirium,  as  well  as  nausea  and  vomiting,  have  been 
observed  to  follow  the  use  of  these  remedies.  It  is  also  worthy 
of  especial  notice  that  their  exhibition  does  not  prevent  the  occur- 
rence of  heart  complication,  and  that  the  liability  to  relapse  ia 
considerable. 

When  pericarditis  supervenes  in  the  course  of  rheumatism,  and 
acute  pain  is  referred  to  the  cardiac  region,  no  time  should  be 
lost  in  applying  three  or  four  leeches,  if  the  patient  has  a  hard 
pulse,  and  is  strong  enough  to  bear  depletion.  Heaviness  of 
manner,  heat  of  skin,  and  any  degree  of  pulmonary  congestion, 
with  a  dry  cough  and  quick  breathing,  are  among  the  indications 
for  their  employment.  Moreover,  the  pain  in  the  chest  alone 
sufficiently  justifies  the  practice,  for  its  continuance  further  excites 
the  action  of  the  heart,  and  aggravates  the  serous  inflammation 
already  begun,  by  accelerating  the  circulation,  and  permitting 
that  extra  motion  to  the  walls  and  valves  of  the  heart  which,  in 
the  progress  of  pericarditis  or  endocarditis,  are  so  much  in  need  of 
rest.  Generally,  I  believe,  a  mustard  poultice,  or  repeated  linseed 
poultices,  will  supply  the  place  of  leeches ;  still  they  are  useful  in 
the  cases  I  have  pointed  out.  Opium,  or  hydrate  of  chloral,  must 
be  resorted  to  whilst  pain  and  sleeplessness  are  leading  symptoms. 
Opium,  especially,  soothes  the  nervous  system,  controls  the  hurried 
circulation,  and  reduces  the  frequency  of  the  pulse. 

In  cases  where  the  temperature  suddenly  rises  very  high,  and 
death  threatens  from  delirium  and  exhaustion,  no  remedy  is  so 
likely  to  save  life  as  the  cold  bath.  It  has  been  employed,  with 
the  best  results,  by  Dr.  Wilson  Fox,  and  some  others  in  cases  of 
hyperpyrexia  in  acute  rheumatism,  when  the  thermometer  regis- 
tered 107°,  108°,  109°,  and  in  one  instance,  recovery  took  place 
after  the  temperature  had  reached  110°. 

These  cases  were  complicated  with  endocarditis,  pericarditis, 
rigidity  of  the  muscles,  delirium,  and  coma.  Dr.  Fox  put  his 
patient  with  a  temperature  of  110°,  into  a  bath  of  9i3°,  and 
reduced  it  gradually  by  adding  lumps  of  ice,  and  pouring  iced 
water  over  the  patient  rapidly.     The  average  temperature  of  the 

*  St.  Thomas's  Hosp.  Reports,  p.  402. 


ACUTE    RHEUMATISM.  667 

bath  was  66°.  In  this  remarkable  case,  the  patient,  a  female  aged 
49,  took  each  day  for  two  days,  eighteen  ounces  of  brandy  in  the 
twenty-four  hours,  sixteen  ounces  of  beef  tea,  four  pints  of  milk, 
and  seven  eggs.*  It  seems  that  we  possess  a  remedial  agent  in 
the  cold  bath  of  extreme  value,  when  venesection,  salicin,  and 
large  doses  of  quinine,  have  signally  failed.  When  a  child  has 
this  very  high  temperature,  and  life  is  despaired  of  through  the 
failure  of  other  remedies,  I  should  unhesitatingly  have  recourse 
to  it. 

Local  applications  are  of  great  value  in  relieving  pain.  The 
affected  joints  should  be  swathed  in  cotton-wool,  and  then  covered 
with  oil  silk,  a  plan  which  conduces  to  the  repose  of  the  parts  and 
to  the  comfort  of  the  patient.  A  piece  of  linen  rag  saturated  in  a 
solution  of  bicarbonate  of  potash  and  laudanum  may  be  had  re- 
course to  if  the  pain  is  severe  and  the  joint  hot.  The  solution 
must  be  warm,  and  cotton-wool  afterwards  applied  to  the  joint. 

The  plan  of  blistering  the  joints,  as  recommended  by  Dr.  Herbert 
Davies,  is  an  excellent  one,  and,  speaking  from  my  own  experi- 
ence, I  should  say  that  nothing  relieves  the  pain  more  effectually 
than  the  application  of  strong  blistering  fluid  to  the  affected  part. 
After  the  application,  the  joint  should  be  protected  with  cotton- 
wool as  just  described.  The  discomfort  caused  by  the  blistering 
soon  passes  off'. 

As  soon  as  the  more  acute  symptoms  begin  to  subside,  bark 
should  be  given,  and  if  the  urine  is  still  high-colored,  potash  should 
be  added  to  it.f  When  the  alkaline  treatment  is  changed  for  the 
tonic,  the  ammonio-citrate  of  iron  with  the  bicarbonate  of  potash 
is  very  useful,:}:  and  later  on  the  syrup  of  the  iodide  of  iron  may 

*  On  Hyperpyrexia,  by  Wilson  Fox,  M.D.,  1871. 
f  Formula  91 : 

B-    Potass,  bicarb.,      . .5J 

Tinct.  cinch,  co., 3y 

Syr.  zingib., ^iij 

Aquam  ad ^iv. — M. 

A  dessertspoonful  three  times  a  day.  For  children  from  eight  to  twelve  years 
of  age. 

X  Formula  92 : 

R.  Potass,  bicarb., 5.j. 

Ferri  et  amm.  citr.,         .......  gr.  xx 

Syr.  aurant., ^iij 

Aquam  cinnamomi  ad    .         .         .         .         .         .         .  §iv. — M, 

A  dessertspoonful  three  times  a  day.  For  children  from  eight  to  twelve  years 
of  age. 


668  DISEASES    OF    CHILDREN. 

be  substituted  with  advantage.  Cod-liver  oil,  too,  is  a  valuable 
remedy  to  children  of  a  strumous  diathesis. 

Too  much  care  cannot  be  exercised  in  restricting;  the  use  of 
animal  food,  for  fear  of  increasing  the  lactic  acid  in  the  blood,  and 
either  fostering  the  disorder,  or  bringing  on  a  relapse,  as  I  have 
already  noticed  ;  hence  the  propriety  of  giving  suitable  food  spar- 
ingly, and  of  a  nou-nitrogenoas  character.  Dr.  James  Andrew 
has  written  an  interesting  paper  on  the  subject.*  An  abundance 
of  milk,  together  with  vegetable  and  farinaceous  food,  such  as 
gruel,  arrowroot,  rice,  and  tapioca  pudding,  are  the  safest  kinds 
of  nourishment  till  every  relic  of  the  disorder  has  disappeared. 
"When  the  complaint  has  vanished,  white  fish,  chicken,  sweetbread, 
etc.,  should  be  taken  in  preference  to  the  stronger  forms  of  animal 
food. 

The  whole  question  of  rheumatic  fever  is  beset  with  difficulties, 
owing  to  the  opposite  opinions  that  prevail  as  regards  the  best 
mode  of  treating  it,  and  the  complications  that  may  spring  up  in 
its  course.  It  behooves  us  to  provide  against  the  latter  difficulty 
by  attacking  the  inflammation  of  internal  organs  vigorously,  and 
without  loss  of  time,  by  subduing  pain,  and  therefore  preventing 
exhaustion,  and  above  all  to  enforce  such  rules  of  living  as  shall 
modify  that  state  of  constitution  favorable  to  the  development  of 
lactic  acid  in  the  blood,  which  favors  the  disease,  promotes  its 
relapse,  and  encourages  its  continuance. 

We  may  repeat  that  it  is  well  to  make  the  alkaline  and  cha- 
lybeate treatment  overlap.  Thus  the  bicarbonate  of  potash  may  be 
continued  some  time  after  the  acute  symptoms  have  passed  away, 
combining  it  with  the  ammonio-citrate  of  iron. 

During  convalescence  we  cannot  overestimate  the  importance  of 
maintaining  the  warmth  of  the  patient  by  suitable  clothing,  and 
by  guarding  against  cold. 

Gout. — Although  gout  does  not  occur,  as  a  rule,  before  the  age 
of  puberty,  it  has  been  met  with  in  young  children.  "  Sir  C. 
Scudamore  was  assured  by  a  gentleman  whose  mother  lalx)red 
under  this  malady,  that  he  was  atttacked  in  the  great  toe  at  eight 
years  of  age,  and  medical  friends  have  informed  me  of  cases  having 
occurred  at  a  still  earlier  period  of  life.     For  my  own  part  I  con- 

*  On  tlie  Treatment  of  Rheumatic  Fever  by  a  Ison-nitrogenous  Diet,  St.  Bartholo- 
mew's Plcspital  Kejiorts,  vol.  x,  p.  359. 


RICKETS   OE   RACHITIS.  669 

fess  I  have  not  seen  a  case  of  true  gout,  that  is,  an  articular  affec- 
tion implicating  the  great  toe,  in  patients  much  under  the  age  of 
twenty."*  Trousseau  calls  attention  to  the  fact  of  an  asthmatic 
Moldavian  boy,  aged  five,  having  a  characteristic  fit  of  the  gout 
in  the  big  toe,  and  that  it  was  tlie  only  instance  he  had  ever  seen 
at  such  an  early  age.f  We  find  urine  laden  with  urates,  scalding 
and  excoriating  the  external  parts  in  young  children,  where  fond 
and  foolish  parents  give  them  too  much  meat,  under  the  impres- 
sion that  this  will  make  them  strono-. 


CHAPTER   XLIX. 

RICKETS    OR    RACHITIS. 

Nature  and  Definition — Physical  and  constitutional  manifestations — State  of  the  cranium — • 
Changes  in  the  thoracic  walls  and  long  bones — Delayed  dentition — Impairment  of 
digestive  functions — Character  of  the  urine — State  of  the  intellect.  Causes  and  Com- 
plications :  Congenital  history — Period  of  commencement — Influence  of  damp  and 
old — Association  with  general  debility,  bronchitis,  cerebral  exhaustion,  laryngismus  and 
hydrocephalus — Its  relation  to  constitutional  syphilis — Parental  manifestations.  Diag- 
nosis :  From  tubercidosis — Scrofula — Syphilis — Hydrocephalus.  Morbid  Anatomy  : 
Deficiency  of  earthy  salts  in  the  bones,  ivhich  are  soft  and  light — Increase  of  fat  and 
watery  elements.  Termination  :  In  recovery,  or  death  from  disease  of  the  lung — 
Spasm  of  the  glottis — Convulsions.  Treatment  :  Importance  of  milk  and  fresh  air — 
Cold  douche  to  the  head  and  belladonna  to  allay  sweating — Hypophosphite  of  lime 
biscuits — Iron — Quinine — Arsenic — Cod-liver  oil  the  chief  remedy — Sea-air  and  sea- 
bathing. 

EiCKETS  is  a  constitutional  malady  manifested  by  depraved 
nutrition,  and  an  alteration  in  the  shape  and  composition  of  the 
bones.  It  is  "the  most  common,  the  most  important,  and  in  its 
effects,  the  most  fatal  of  diseases  which  exclusively  affect  chil- 
dren "  (Jeuner). 

"  Rickets,"  according  to  Holmes  Coote,  '^  though  not  unknown 
to  the  ancients,  seems  to  have  been  scarcely  recognized  in  iSTorthern 
Europe  till  the  beginning  of  the  seventeenth  centurj^,  when  it 
spread  over  England  and  other  European  countries.":}: 

We  find  on  the  authority  of  Whistler,  Glisson,  Bate,  and  others, 
that  when   the   disease   first   appeared   in   the  western  parts  of 

*  Gout  and  Eheumatic  Gent,  by  A.  B.  Garrod,  M.D.,  1859,  p.  256. 

t  See  Chapter  XXIV,  p.  397,  On  Asthma. 

X  St.  Bartholomew's  Hospital  Reports,  vol.  v,  p.  125. 


670  DISEASES   OF   CHILDREN. 

Eno'latid,  at  the  period  just  alluded  to,  it  was  called  the  Englisli 
malady.*  A  term  still  retained  in  Germany,  at  least  in  the 
lecture-room,  at  the  present  day. 

In  England,  Holland,  and  some  districts  of  France,  it  is  now  one 
of  the  commonest  diseases  of  children.  It  is  occasionally  met 
with  among  the  rich,  and  those  who  are  reared  in  luxury,  but  it 
occurs  more  frequently  among  the  poor,  and  is  best  studied  in 
hospital  practice.  It  may  be  witnessed  among  strumous  and  tuber- 
cular children,  but  whether  this  is  accidental,  or  whether  rachitis 
holds  any  direct  relation  to  these  diatheses,  or  is  a  special  diathesis, 
is  a  matter  not  yet  settled.  Opinions  are  divided  on  the  question. 
Certain!}^  we  often  see  rickets  occur  independently  of  struma  or 
tubercle.  It  is  not,  strictly  speaking,  a  disease  of  the  osseous 
system,  but  one  of  malnutrition,  and  it  belongs  to  an  unhealthy 
state  of  the  constitution,  "  Rickets  differs  from  scrofulous  affec- 
tions in  this  respect,  that  while  frequently  associated  with  inflam- 
matory conditions  it  is  not  essentially  an  inflammation. "f 

Rickets  is  a  non-febrile  malady,  and  sufferers  from  it  have  a 
bodily  temperature  according  to  some  authorities  a  little  below  the 
normal.  In  twenty  cases  under  my  care,  I  found  the  morning  and 
evening  temperature  so  nearly  normal  that  the  difference  was  not 
worth  notice.  The  features  which  indicate  the  affection  are  now 
very  well  recognized,  owing  to  the  clinical  researches  of  Kolliker^ 
Virchow,  Jenner,:j:  Gee,§  Volkmann,  Rokitansky,  Holmes  Coote, 
and  other  authorities.  There  is,  in  the  first  place,  always  more  or 
less  cachexia,  the  child  never  looking  thoroughly  healthy.  The 
head  in  some  cases  is  markedly  deformed,  and  looks  unusually 
laro-e ;  but  this  is  to  some  extent  deceptive,  because  the  face  is  so 
shrunken  and  imperfectly  developed  that  it  makes  the  upper  part 
of  the  head  look  larger  than  it  really  is.  In  seventeen  cases  of 
rickets,  the  average  age  being  4.72,  the  average  circumference  of 
the  heads  was  21.22.  In  an  equal  number  of  non-rachitic  chil- 
dren, with  an  average  age  of  6.05,  the  average  circumference  was 
19.95.11  The  bones  of  the  face  grow  more  rapidly  in  children  than 
the  bones  of  the  cranium ;  on  the  other  hand,  in  overgrown  men 

*  Dictionary  of  Medicine,  vol.  iii,  1858,  p.  643. 

t  Jones  and  Sieveking's  Pathological  Anatomy,  by  Payne,  1875,  p.  845. 

X  Medical  Times  and  Gazette,  1860. 

§  On  Rickets,  St.  Bartholomew's  Hospital  Reports,  vol.  iv,  1868. 

II  Discussion  on  Rickets,  Pathological  Society,  The  Lancet,  1880,  vol.  ii,  p.  1017. 


EICKETS    OR   RACHITIS.  671 

or  giants,  the  skull  appears  small  and  the  forehead  low,  because 
the  bones  of  the  face,  like  those  of  the  limbs,  have  increased  out 
of  all  proportion  to  those  of  the  cranium.  In  rickets,  nutrition 
and  growth  are  checked,  hence  the  face  is  small.*  The  sutures 
are  depressed,  and  feel  open  when  the  hand  is  passed  along  them  ; 
the  fontanelles  remain  unclosed,  often  to  the  middle  of  the  second 
year.  The  bones  of  the  cranium  become  abnormally  thickened, 
and  the  whole  skull  appears  flattened  at  the  vertex,  and  also  at  the 
sides,  so  as  to  lose  its  vaulted  form  and  become  boxlike.  The  head 
is  also  long  and  broad,  and  the  width  between  the  eyes  is  increased. 
The  size  of  the  cranium  is  ther'efore  large,  the  sutures  remain 
open,  and  the  parietal  and  frontal  bones  are  largely  developed. 
Between  the  ill-developed  cranium  and  the  equally  ill-nourished 
brain,  there  is  often  fluid,  simply  filling  up  the  space,  and  not  the 
result  of  any  inflammatory  effusion.  Hence  this  condition  has 
been  termed  "  spurious  hydrocephalus.''  In  rachitis  the  cranium 
is  frequently  unsymraetrical,  a  matter  worth  attending  to  in  diag- 
nosis. 

The  next  characteristic  feature  of  rachitis  is  found  in  the  osseous 
walls  of  the  thorax.  Owing  to  the  softness  of  the  ribs  (for  the 
imperfect  ossification  of  certain  bones  is  a  pathological  feature  of 
this  disease)  thej^  yield  to  the  external  pressure  of  the  atmosphere 
during  inspiration,  and  hence  become  flattened  laterally  and  bent 
inwards ;  a  transverse  constriction  is  often  seen  at  the  level  of  the 
junction  of  the  sternum  and  ensiform  cartilage,  due  to  the  great 
difficulty  of  thoroughly  filling  the  lowest  part  of  the  lungs  with 
air.  "  A  second  cause  is  the  outward  pressure  on  the  lower  ribs, 
caused  by  enlargement  of  the  liver  and  spleen,  often  present  in 
these  cases ;  and  a  third  (which  seems  rather  theoretically  proba- 
ble than  absolutely  proved)  is  the  inward  traction  upon  the  car- 
tilaginous extremities  of  the  ribs  by  the  attachments  of  the  dia- 
phragm. The  result  is  a  constriction  of  the  chest,  much  as  though 
a  string  had  been  tied  round  it  below  the  heart,  whilst  its  apex  is 
distended.  Except  in  very  severe  cases,  this  deformity  of  the  chest 
may  be  expected  to  be  effaced  as  the  child  recovers  from  the  con- 
stitutional taint."t 

In  a  rickety  child,  under  my  care  in  1874,  aged  11  years,  with 

*  See  Mr.  Shaw's  Observations  on  Lateral  Curvature  and  Eickets,  Holmes's  System 
of  Surgery,  vol.  v,  second  edit.,  p.  871. 

t  Surgical  Treatment  of  Children's  Diseases,  by  T.  Holmes,  1868,  p.  343. 


672  DISEASES   OF   CHILDREN. 

congenital  hypertrophy  of  the  heart  and  mitral  disease,  the  whole 
left  side  of  the  sternum  was  rounded  and  elevated,  and  extremely 
convex,  whilst  the  thorax  generally,  from  the  amount  of  emphy- 
sema present,  was  very  barrel-shaped  and  prominent.  In  a  rickety 
boy,  aged  nine,  under  my  care  in  1878,  with  mitral  regurgitation 
and  hypertrophy  after  rheumatic  fever,  the  cardiac  region  was  also 
very  rounded  and  elevated,  but,  as  in  the  former  case,  there  was  a 
considerable  depression  or  groove  running  backwards  longitudi- 
nally from  the  sternum  below  the  nipples — a  groove  arising  not  so 
much  from  deficiency  of  air  entering  the  chest,  as  from  the  soften- 
ing of  the  bones  and  their  tendency  to  fall  inwards.  The  common 
changes  are  a  lateral  flattening  of  the  chest,  and  a  prominence  of 
the  sternum — in  many  cases,  instead  of  being  nearly  circular  as  in 
health,  it  becomes  triangular,  and  the  patient  presents  the  well- 
known  appearance  of  "  pigeon  breast."  This  condition  is  alluded 
to  under  chronic  enlargement  of  the  tonsils.* 

From  the  weight  of  the  body  the  bones  of  the  extremities  yield, 
and  the  ligaments,  bearing  an  unequal  strain,  cause  the  articula- 
tions to  become  distorted,  and  hence  we  meet  with  weakened 
joints  and  bow-legs  ;  the  femur  and  the  tibia  are  bent  forward, 
the  arch  of  the  foot  is  destroyed,  while  the  outlet  of  the  pelvis 
is  narrowed.  The  limbs  become  so  weak  that  a  child  of  four  or 
five  years  of  age  may  not  be  able  to  walk,  and  if  it  can,  it  will 
fall  down  on  meeting  with  any  obstacle  in  its  way.  The  bones 
too,  from  being  soft,  readily  fracture  from  slight  blows.f 

The  ribs  and  long  bones  undergo  enlargement,  and  become  soft, 
spongy,  and  light,  whilst  the  parietal  and  temporal  bones  also 
become  thick  and  spongy,  and  the  vertebral  colunin  often  yields 
and  becomes  curved.  The  gravest  result  of  the  osseous  lesions  of 
rickets  lies  in  the  ill-development  of  the  pelvis,  the  cavity  of  which 
may  be  simply  narrow  from  malnutrition  of  its  bony  walls,  or 
absolutely  deformed,  from  the  softened  bones  falling  in  and  nar- 
rowing the  brim.  Hence  follows  iu  after-life  a  frequent  cause  of 
difiicult  labor  in  women  ;  and  even  in  the  male,  the  extraction  of 
large  calculi  during  lithotomy  may  be  impeded  by  rachitic  defor- 
mity of  the  pelvis.     In  the  case  of  a  boy,  aged  three  years,  under 

*  See  Chap.  XIII,  p.  159. 

f  The  incomplete  or  "  green-stick  "  fractures  frequent  in  rickety  children  are  well 
known  to  the  surgeon.  Tliey  usually  involve  the  radius  and  the  ulna,  but  are  not  rare 
in  other  long  bones. 


RICKETS    OR    RACHITIS.  673 

my  care,  botli  clavicles  stood  out  at  a  sharp-pointed  angle  in  the 
centre,  as  though  they  had  been  fractured  and  badly  united.  The 
lower  ribs  were  nodulated  where  they  joined  their  cartilages,  and 
pressed  out  in  a  fanlike  shape  from  the  enlarged  viscera  beneath ; 
the  upper  part  of  the  chest  was  narrow  and  contracted,  the  ax- 
illary and  infraclavicular  regions  shrinking  in,  the  spine  was 
curved,  the  scapulae  were  deformed,  and  the  joints  of  the  larger 
articulations  so  loose  that  they  could  be  twisted  in  any  direction 
without  difficulty. 

But  the  most  pathognomonic  symptom  is  the  "  row  of  beads" 
along  the  junction  of  the  ribs  with  their  cartilages,  caused  by 
slio-ht  enlargcement  of  the  ends  of  the  ribs;  this  has  been  termed 
"  the  rachitic  garland."  Dr.  Hilton  Fagge  states  that  "the  en- 
largement is  often  much  more  marked  on  the  pleural  side  than 
towards  the  surface."*  The  articular  parts  of  the  bones  of  the 
extremities  enlarge,  causing  a  "  double-jointed  "  appearance  very 
conspicuous  at  the  wrists,  due  to  the  enlargement  of  the  epi- 
physes. 

Eickety  children  are  short  and  of  stunted  stature.  This  would 
appear  to  depend  on  an  arrest  in  the  growth  of  the  bones  ;  denti- 
tion is  delayed  and  irregular,  the  teeth  not  appearing  in  some 
cases  till  the  fifteenth  or  twentieth  month.  In  a  case  under  my 
care  in  1874,  a  child,  said  to  have  been  three  years  old,  had  no 
appearance  of  a  tooth.  In  a  case  of  well-marked  rickets  in  a 
boy,  "  the  first  tooth  did  not  appear  till  he  was  four  years  old."t 
The  teeth  are  small,  black,  ragged,  and  pointed,  they  decay  early 
and  soon  fall  out. 

The  constitutional  symptoms  are  very  marked.  The  children 
are  pallid,  with  prominent  veins;  they  shrink  and  fall  away,  and 
become  thin.  There  are  thirst,  accelerated  pulse,  and  flushing  of 
the  face  at  night,  with  broken  sleep  in  all  aggravated  cases.  Fret- 
fulness  and  irritability  are  common.  Some  children  almost  cry 
when  looked  at,  and  are  very  timid  and  alarmed  when  approached. 
Such  cases  are  sometimes  followed  by  squinting,  defective  vision, 
and  hesitation  in  speech,  w^hich  gradually  disappear  as  the  general 
condition  improves.  Headache  after  exertion,  or  inability  to  take 
food,  is  a  common  and  persisting  symptom.     The  child  yawns  and 

*  Discussion  on  Rickets,  Pathological  Society,  Nov.,  1880. 
f  Steiner's  Di-^eases  of  Children,  by  Lawson  Tait,  1874,  p.  222. 

43 


674  DISEASES   OF   CHILDREN. 

sighs  repeatedly  in  the  daytime,  puts  his  hand  to  his  head  as  if  to 
remove  something,  and  then  closes  his  eyes  and  falls  off  to  sleep 
with  one  or  hoth  eyes  half  open,  for  a  few  minutes,  easily  waking 
"up  again  from  any  noise  or  disturbance,  and  uttering  a  distressing 
cry.  If  toys  are  offered  to  appease  him,  he  angril}^  tosses  them  on 
one  side,  and  refuses  to  be  friendly  with  those  who  have  shown 
him  uniform  kindness.  These  symptoms  may  of  course  be  seen 
in  cerebral  exhaustion  from  other  causes,  and  they  are  probably 
rather  more  common  in  true  hydrocephalus  than  in  rickets. 

Should  an  eruptive  illness,  as  scarlet  fever  or  measles,  supervene, 
the  rachitic  condition  becomes  aggravated. 

The  abdomen  is  usually  large*  and  distended.  The  Germans 
call  it  Froschbauch  (Frogbelly),  which  accurately  describes  the  ap- 
pearance; the  liver  may  be  felt  projecting  sharply  below  the  ribs, 
and  the  spleen  is  often  very  large.  The  lymphatic  glands  may 
sometimes  be  felt  enlarged  and  indurated  in  the  neck,  groins,  and 
axilla.  Children  in  some  cases  have  a  sallow,  greenish,  or  chlo- 
rotic  tint.  This  was  very  noticeable  in  a  little  girl  I  saw,  who 
was  suffering  from  tubercular  disease  in  the  lung  at  the  same 
time. 

The  head  becomes  unusually  large,  and  perspires  remarkably; 
beadlike  drops  may  be  seen  standing  on  the  face,  whilst  the  trunk 
and  limbs  are  hot;  the  veins  are  prominent  over  the  temples  and 
forehead,  and  sometimes  in  the  neck  and  thorax.  Occasionally  the 
carotid  arteries  pulsate  strongly,  and  the  heart's  action  is  irritable 
and  excited ;  but  these  symptoms  are  absent  in  some  cases  marked 
by  great  deformity,  while  found  at  other  times  in  less-pronounced 
eases.  The  child  kicks  off  the  clothes  at  night,  and  exposes  his 
limbs.     These  are  among  the  earliest  symptoms. 

The  appetite  is  capricious,  and  there  is  oppression  and  uneasiness 
after  food.  The  motions  are  like  those  observed  in  some  forms  of 
diarrhoea  Qientery),  being  curdy  and  whitish ;  because  the  food 


*  "The  abdomen  is  very  large,  and  often  appears  enormously  distended  when  com- 
pared with  the  narrow  and  distorted  chest.  This  enlargement  of  the  belly  is  due  to 
depression  of  the  diaphragm  and  diminished  capacity  of  the  thorax,  which  force  down 
the  liver  and  spleen  below  the  level  of  the  ribs,  to  increased  shallowness  of  the 
pelvis,  to  the  flabby  condition  of  the  abdominal  muscles  favoring  the  accumulation  of 
flatus  generated  by  the  digestive  derangement,  and  in  some  cases  to  actual  increase  in 
size  of  the  liver  and  sjaleen." — Wasting  Diseases  of  Children,  by  Eustace  Smith,  M.D., 
2d  edit.,  p.  113. 


EICKETS   OR   RACHITIS.  675 

passes  throngli  the  bowels  partly  unchanged,  the  digestive  func- 
tions having  exerted  little  influence  upon  it. 

According  to  Frerichs,  both  the  liver  and  spleen,  in  some  cases 
of  rickets,  are  affected  with  amyloid  degeneration,* 

Dr.  Dickinson  resards  the  swellino-  of  the  abdominal  organs  as 
much  a  part  of  rickets  as  the  changes  in  the  bones,  and  he  believes 
the  two  to  be  closel}^  analogous.  The  spleen,  liver,  and  lymphatic 
glands  become  enlarged,  the  spleen  most,  the  mesenteric  glands 
least  so.  "  There  is  no  new  growth  or  deposit,  only  an  irregular 
development  of  the  proper  tissues  of  the  organs.  .  .  .  The  earthy 
salts  woukl  seem  to  be  diminished  in  the  viscera  as  in  the  bones. "f 

The  urine  may  contain  phosphates  and  urates,  but  it  is  usually 
clear  and  pale,  even  when  the  appetite  is  most  morbid.  "When 
there  is  diarrhoea  the  motions  are  green,  slimy,  and  offensive,  or 
deficient  in  bile;  audit  is  in  these  cases  with  chronic  dyspepsia 
that  the  urinary  secretion  is  most  affected.  In  twelve  consecutive 
cases  of  rickets  admitted  under  my  care  at  the  Samaritan  Hos- 
pital, I  found  the  urine  of  acid  reaction  in  all;  five  contained 
urate,  and  in  three  of  these  the  deposit  was  very  copious;  two 
contained  phosphates,  and  the  remaining  specimens  were  clear  and 
normal.  The  highest  specific  gravity  was  1030,  the  lowest  1020. 
"The  phosphates  are  more  abundant  than  in  health,  and  a  con- 
siderable sediment  of  oxalate  of  lime  is  not  unfrequent;  audit 
has  been  observed  that  urinary  calculi  are  frequent  in  rachitic 
children."  (Copland.)  My  colleague,  Mr.  Alban  Doran,  in  1877, 
removed  an  oxalate  of  lime  calculus  from  the  bladder  of  a  rickety 
girl,  who  was  admitted  into  the  Samaritan  Hospital  under  my 
care  with  symptoms  of  vesical  irritation.^  Large  quantities  of 
uric  acid  crystals  have  also  been  noticed  (Hilton  Fagge). 

The  swollen  joints  and  distorted  limbs  are  very  painful.  The 
little  patient  screams  even  when  lifted  up  gently,  which  is  proba- 
bly due  to  tenderness  of  the  periosteum,  where  morbid  changes 
are  going  on ;  it  is  subject  to  slight  muscular  spasms,  clenching  its 
hands  tightly,  and  prefers  to  sit  and  lie  about  instead  of  join- 
ing in  the  play  of  its  companions.  These  spasms  may  be  taken 
for  slight  convulsions  from  cerebral  disease,  especially  if  there  be 
malformation  of  the  skull,  which  has  been  erroneously  attributed 
to  true  hydrocephalus. 

*  Dis-^ases  of  the  Liver,  New  Syd.  Soc,  1861,  vol.  ii,  p.  175. 

f  Discussion  on  Eickets,  Pathological  Society,  The  Lancet,  1880,  vol  ii,  p.  938. 

J  See  Chap.  XXIV,  p.  264,  On  Diseases  of  the  Urinary  Organs. 


67G  DISEASES    OF    CHILDREN. 

As  regards  the  state  of  the  intellect,  rickety  children  are  gener- 
ally dull  and  stupid,  and  in  some  cases  there  is  an  approach  to 
idiocv ;  there  is  lethargy  in  all  their  movements  and  actions,  and 
they  do  not  exhibit  the  precocity  of  the  tuberculous.  Their  powers 
of  memory  are  defective,  and  they  have  a  difficulty  in  acquiring 
knowledge ;  even  when  the  desire  is  great  they  fail  under  the 
strain,  and  headache,  restless  nights,  and  exhaustion  are  common 
manifestations  of  the  constitutional  taint.  "When  precocity  of 
intellect  is  shown  (which  I  think  very  rare),  the  explanation  of- 
fered is,  that  the  open  sutures  allow  the  brain  to  expand,  and  its 
circulation  and  development  proceed  more  rapidly  than  when  the 
cranial  bones  have  been  unvielding;  but  this  does  not  seem  to  me 
a  satisfactory  solution,  for  when  the  head  is  disproportionately 
large,  my  experience  is  in  favor  of  a  tardy  and  not  a  precocious 
development  of  the  mental  faculties. 

Causes. — Parents  from  constitutional  infirmity,  excesses  of  all 
kinds,  and  living  in  crowded  and  unhealthy  localities,  impart  a 
general  debility  to  their  offspring,  which  favors  the  development 
of  scrofulous  disease,  and  in  a  less  degree,  of  rickets.  Early 
marriages  of  tlie  artisan  classes,  and  long  hours  of  labor  passed 
in  overcrowded  and  badly-ventilated  workrooms,  are  powerful 
factors  in  provoking  the  disorder ;  for,  in  addition  to  the  physical 
exhaustion  of  the  parents,  there  is  also  a  mental  disquietude  which 
has  a  similarly  exciting  tendency  in  the  development  of  rickets. 
"When,  as  too  frequently  happens,  the  children  of  such  parents  are 
not  properly  fed,  or  a  farinaceous  diet  takes  the  place  of  the  ma- 
ternal milk,  or  they  are  prematurely  weaned  and  neglected,  then 
rickets  is  invited.  Rickets  is  intimately  associated  with  bad  feed- 
ing and  faulty  assimilation.  According  to  Mr.  Hutchinson,  it  is 
a  diet  disease,  defective  food  being  probably  the  main  cause.  In 
92  per  cent,  of  Dr.  Baxter's  cases  farinaceous  food  of  one  kind  or 
another  had  been  given  before  the  age  of  twelve  months.*  "  What- 
ever external  or  extrinsic  circumstances  are  favorable  to  the  for- 
mation of  watery  blood  (hydrsemia)  in  a  child,  seem  favorable  to 
the  development  of  rickets."f 

Though  rickets  is  a  disease  peculiar  to  infancy  and  very  early 
life,  there  is  evidence  to  prove  that  it  is  sometimes  congenital. 
From  constitutional  vice  of  the  parents  it  may  show  itself  in  the 

*  Discussion  on  Rickets,  Pathological  Society,  the  Lancet,  18S0,  vol.  ii,  p.  1017. 
f  Rickets,  by  Dr.  Aitken,  Reynolds's  System  of  Medicine,  vol.  i,  p.  801. 


EICKETS    OR    RACHITIS.  677 

offspring,  and  cases  are  recorded  where  it  lias  attacked  the  foetus 
in  utero.*  But  the  evidence  is  not  very  confirmatory  of  such  a 
fact.  Hilton  Fagge  and  Dr.  Baxter  are  of  opinion  that  an  infant 
is  never  born  with  so-called  "  fetal  rickets. "f  Rickets  woukl  ap- 
pear to  be  most  common  up  to  the  second  year.  It  is  rare  after 
the  period  of  the  first  dentition  in  healthy  children.  "Rickets," 
says  Holmes  Coote,|  "commences  at  the  time  of  life  when  the 
growth  of  bone  is  most  active,  namely,  in  many  about  the  first  or 
second  year."  According  to  Guerin,  "in  346  cases  the  disease 
commenced  98  times  in  the  first  year,  176  times  in  the  second  year, 
85  times  in  the  third  year,  19  times  in  the  fourth  year,  10  times 
in  the  fifth  3'ear,  twice  in  the  sixth  year,  extending  to  the  twelfth." 
He  mentions  that  in  three  instances  it  was  congenital.  Mr.  Stan- 
ley reckons  the  most  frequent  period  from  the  eighteenth  to  the 
twenty-fourth  month. §  It  is  common  in  damp  and  cold  climates, 
wdiere  children  are  not  enough  in  the  open  air,  and  hence  it  may 
be  that  the  disease  is  of  greater  frequency  in  northern  than  in 
southern  latitudes. 

There  is  often  a  hereditary  history  of  phthisis  and  brain  disease. 
Three  children  out  of  five  in  one  family  I  heard  of  were  all  rickety, 
and  died  of  mesenteric  disease  and  convulsions.  One  case  came 
under  my  own  notice;  a  boy  who  was  a  twin,  aged  five  years,  was 
admitted  under  my  care  at  the  Samaritan  Hospital,  in  June,  1877, 
with  a  deformed  chest  and  loose  joints.  I  received  the  following 
history:  His  mother  was  delicate,  and  there  was  phthisis  on  the 
father's  side  of  the  family.  The  child  had  a  convulsion  during 
delayed  dentition  ;  since  then  he  had  been  losing  flesh,  and  was 
weak,  irritable,  and  spiteful.  His  appetite  was  ravenous,  and  he 
was  never  satisfied  with  the  food  given  him.  He  brought  up  a 
great  deal  of  blood,  and  though  the  evening  temperature  reached 
102.6°  and  the  pulse  140,  no  organic  change  could  be  detected. 
After  a  few  days  he  began  to  whoop,  but  the  temperature  gradually 
fell  to  normal,  and  the  cough  subsided  ;  the  belly  was  large,  the 
teeth  black  and  decayed,  and  there  was  ulceration  of  the  gums. 
He  left  the  hospital  much  relieved. 

*  "  Rachitis  is  sometimes  developed  in  the  foetus  whilst  yet  in  its  mother's  womb, 
even  when  her  health  does  not  appear  changed.  The  museums  of  pathological  anat- 
omy contain  several  skeletons  of  those  children  rachitic  from  birth." — M.  Bouchut,  On 
Diseases  of  Infants  and  Children,  1855  ;  translated  by  Peter  Hinckes  Bird,  F.E.C.S. 

t  Op.  cit.,  p.  1018. 

X  Log.  cit.,  p.  128.  ^  Diseases  of  Bones. 


678  DISEASES    OF    CHILDREN, 

Whatever  reduces  the  general  strength,  or  interferes  with  diges- 
tion and  assimilation,  may  induce  rickets.  "  Thus  it  is  particu- 
larly remarked  among  the  children  of  the  poor,  who  are  weaned 
early,  and  who  are  before  the  proper  age  placed  at  the  family  table 
to  be  fed  with  soups,  broths,  vegetables,  meats,  etc."  (Bouchut.) 

The  rickety  condition  is  associated  with  general  debility,  and  is 
often  complicated  with  bronchitis,  pneumonia,  whooping  cough, 
the  eruptive  fevers,  tubercular  disease  of  the  thorax  or  abdomen, 
laryngismus,  and  hydrocephalus.  Any  of  these  disorders  have  an 
unfavorable  eflect  upon  the  progress  of  the  malady,  for  whatever 
reduces  the  o-eneral  strensfth  and  weakens  the  constitution  is  cer- 
tain  to  retard  recovery  when  favorable  symptoms  have  commenced. 

Yogel  believes  that  constitutional  syphilis  in  the  parent  may 
cause  rickets  in  children,  and  he  is  also  under  the  impression, 
which  I  think  cannot  be  altogether  denied,  that  rickets  is  some- 
times hereditary.  "In  these  cases  the  father  and  mother  usually 
display  the  peculiar! 3^  shaped  rachitic  head,  with  its  boldly  pro- 
jecting tuberosities  of  the  frontal  and  parietal  bones."*  Of  100 
cases  of  cranio-tabes  collected  by  Drs.  Barlow  and  Lees,  70  showed 
a  marked  degree  and  30  a  slight  degree  of  the  affection.  There 
were  proofs  of  syphilis  in  47  instances,  35  of  these  being  among 
the  well-marked  cases  of  cranio-tabes.  The  authors  came  to  the 
conclusion  that  syphilis  was  the  largest  factor  in  the  production 
of  cranio-tabes.  It  would  seem  that  the  connection  between 
cranio-tabes  and  rickets  is  very  close,  and  that  both  afiections 
may  originate  in  syphilis. f  M.  Parrot  believes  syphilis  to  be  a 
cause  of  rickets. 

The  diagnosis  of  this  disorder  is  not  difficult.  The  diathesis  of 
rickets  may  be  confounded  with  that  of  tuberculosis  and  syphilis, 
^■et  their  local  distinctive  characters  are  clear,  and  can  hardly  be 
mistaken  when  carefully  compared  with  one  another.  The  general 
symptoms  are  diflerent,  the  progress  of  the  disorder  is  different, 
and  the  changes  in  the  bones  are  absolutely  pathognomonic  ;  but 
since  tubercular  and  syphilitic  children  may  become  rickety 
through  a  want  of  vital  power  to  carry  on  health}'  nutrition,  these 
disorders  ought  not  to  preclude  the  idea  of  their  occasional  pres- 
ence in  common.  "We  have  alread}^  seen  that  they  do  occur  with 
rickets,  and  that  the  existence    of   either  may  induce  rachitic 

*  Vogel,  Diseases  of  Children,  1874,  p.  532. 

t  Patliology  of  Rickets,  Brit.  Med.  Jour.,  November  20th,  1880. 


RICKETS   OR   RACHITIS.  679 

chano-es.  I  have  seen  a  few  instances.  Tuberculosis  is  more 
hereditary  than  rickets,  but  the  latter  disease  is,  nevertheless,  wery 
often  transmitted  from  parent  to  oftspring.  An  important  point 
in  the  diagnosis  from  hydrocephalus  is  that  the  fontanelles  are 
depressed;  they  do  not  rise  above  the  level  of  the  rest  of  the  scalp, 
and  the  opening  is  simply  due  to  an  arrest  in  the  osseous  develop- 
ment. The  antero-posterior  diameter  is  longer  than  in  hydro- 
cephalus; whilst  in  the  latter  affection  the  head  is  wider,  and  the 
face  smaller.  The  change  in  the  articulations,  the  large  joints, 
the  beaded  ribs,  and  the  alteration  in  the  contour  of  the  thoracic 
walls,  are  all  distinctive  marks  of  rickets,  which  show  themselves 
early,  and  cannot  be  mistaken  for  any  other  disease.  "  It  is 
strange  to  see  a  little  child  sitting  placidly  on  the  bed,  without 
moving  for  hours  together— its  legs  placed  so  as  to  escape  pressure, 
its  spine  bowed,  its  head  thrown  backward,  the  chief  weight  of 
its  body  cast  on  its  arms  ;  and  to  know  that,  notwithstanding 
the  apparent  calm,  the  tiny  thing  is  indeed  fighting  the  battle  of 
life  ;  for  it  is  striving  with  all  the  energy  it  has,  to  keep  in  constant 
action  every  one  of  its  muscles  of  inspiration — endeavoring  so  to 
supply  the  mechanical  defects  of  its  respiratory  apparatus,  due 
to  the  softening;  of  the  ribs.  It  wants  no  tovs.  It  is  the  best 
of  children  if  you  only  leave  it  alone ;  move  it,  and  you  inflict 
pain  upon  its  tender  frame ;  show  it  the  horse  or  the  doll  that 
was  once  its  delight,  and  it  turns  away  its  head,  or  stares 
vacantly ;  to  notice  would  divert  its  attention  too  much  from  the 
performance  of  those  respiratory  movements  which  are  essential 
to  its  existence."" 

Morbid  Anatomy. — The  composition  of  the  bones  shows  a  defi- 
ciency of  lime  salts,  and  an  increase  in  fat,  watery  elements,  and 
carbonic  acid.  The  bones  are  soft,  light,  and  easily  bent  or  broken. 
They  contain  a  deficiency  of  earthy  salts,  because  those  salts  have 
never  been  deposited  in  them ;  just  as  in  mollities  ossium  the  bones 
are  soft,  because  their  earthy  salts  have  been  removed  by  absorp- 
tion. The  lacunee  are  enlarged,  and  there  is  a  great  thickening  of 
the  periosteum.  The  malnutrition  of  the  system  interferes  with 
the  gradual  conversion  of  the  deeper  layers  of  the  periosteum  and 
articular  cartilage  into  bone;  the  bone  when  formed  is  imperfect, 
and  softer  than  it  should  be.  The  morbid  condition  of  the  osseous 
system  brings  about  visceral  changes,  especially  in  the  thorax, 

*  Rickets,  by  Sir  W.  Jenner,  Bart.,  Med.  Times,  1860,  p.  415. 


680  DISEASES    OF    CHILDEEI^. 

where  respiration  is  so  iiuich  impeded,  but  special  changes  in  the 
internal  organs  due  to  rickets  have  not  been  very  clearly  made 
out.  The  w^rists  are  the  first  parts  of  the  body  generally  to  show 
these  changes,  the  ends  of  the  radius  being  large  and  distorted, 
and  then  come  the  sternum  and  ribs,  often  irregularly  projecting 
and  flattened. 

Dr.  Goodhart  has  noticed  the  blood  in  many  cases  of  rickets 
to  be  deficient  in  corpuscles  in  some  and  in  coloring  matter  in 
others.* 

In  mild  cases  rickets  is  capable  of  recovery  and  cure,  the  disease 
being  arrested  as  the  general  health  improves;,  but  there  will  be 
no  chance  of  this  whilst  the  first  dentition  lasts.  The  softened 
bones  may  become  firm  and  consolidated,  but  the  deformity  re- 
mains for  years  or  through  life.  Ultimately  the  distortion  of  the 
long  bones  is  in  natural  course  remedied  by  their  concavities  filling 
with  osseous  buttresses. 

If  disease  of  the  lungs  ensue,  and  the  state  of  the  thoracic  walls 
leads  to  imperfect  expansion  of  the  pulmonary  lobules,  emphysema 
or  chronic  solidification  of  the  lung-tissue  may  arise,  and  cause 
dyspnoea  and  chronic  catarrh,  which  are  apt  to  slowly  wear  out  the 
child's  strength.  Bronchitis,  when  at  all  acute  or  recurrent,  is 
usually  fatal  to  rickety  children ;  the  ribs  fall  in  with  the  increased 
respiratory  efibrts  required,  and  the  feeble  heart  cannot  overcome 
the  blood  stasis  in  the  lungs.  In  one  case  under  my  care,  where 
the  constitution  was  lowered  by  convulsions  and  laryngismus,  the 
infant,  seven  months  old,  died  from  spasm  of  the  glottis.  Laryn- 
gismus stridulus  is  always  associated  with  rickets.  "  I  have  seen 
acute  rickets  twice  fatal  in  children  affected  by  constitutional 
syphilis. "t 

Treatment. — In  attempting  to  cure,  or  arrest  the  disease,  the  first 
and  most  important  point  is  to  ascertain  the  cause  in  operation 
which  has  produced  it.  If  it  has  appeared  during  the  time  when 
the  child  is  still  suckled  at  the  breast,  it  may  be  that  the  mother 
or  the  nurse  cannot  nourish  it,  and  then  proper  food  must  be 
supplied.  To  speak  generally,  it  may  be  said  that  the  victims 
of  this  disorder  should  be  at  once  supported  by  plain  and  simple 
food — such  food  as  can  be  assimilated  and  easily  digested, 
according  to  the  age  and  strength  of  the  sufferer.     Milk  should 

*  The  Lancet,  1881,  vol.  i,  p.  40. 

f  Steiner's  Diseases  of  Children,  by  Lawson  Tait,  p.  311. 


RICKETS    OR    RACHITIS.  681 

enter  largely  into  the  diet  at  all  stages.  If  the  child  is  an  infant,  and 
the  mother's  milk  is  good,  it  should  be  kept  at  the  breast  for  the 
full  period  ;  if  it  has  been  weaned,  and  is  not  more  than  two  years 
old,  there  is  no  better  form  of  nutriment  than  a  plentiful  supply 
of  good  cow's  milk.  Beef  tea,  or  other  animal  broths  may  be 
given  according  to  the  discretion  of  the  physician. 

In  the  south  of  France  it  is  found  that  puppies  fed  on  human 
milk  become  rickety,  and  recover  when  again  fed  on  their  mother's 
milk.  It  has  been  proposed  to  try  bitch's  milk  for  the  treatment 
of  rickets  in  the  human  infant. 

Pure  bracing  air  and  warm  clothing  are  important,  and  a  seaside 
residence,  when  it  can  be  obtained,  will  improve  the  general  nutri- 
tion. When  there  are  no  contraindications  such  children  should 
be  out  of  doors  in  the  daytime.  These  patients  should  lie  on 
mattresses  instead  of  soft  beds,  and  the  pillow  should  be  so 
arranged  that  the  head  does  not  sink  into  it,  as  this  is  certain  to 
increase  the  restlessness  and  sweating.  To  arrest  the  exhausting 
perspirations,  the  head  may  be  douched  with  cold  water  night 
and  morning,  and  the  body  quickly  immersed  in  a  tepid  bath  con- 
taining Tidman's  sea  salt.  - 

The  tincture  of  belladonna  is  useful  in  combination  with  iron  to 
allay  sweating. 

The  hypophosphite  of  lime  biscuits  prepared  by  Van  Abbott, 
Princess  Street,  London,  at  the  suggestion  of  Mr.  "W.  Adams,  may 
be  given  with  advantage.  Each  biscuit  contains  five  grains  of 
the  hypophosphite  of  lime,  and  one  may  be  taken  three  times  a 
day. 

If  the  bowels  are  deranged,  and  digestion  is  not  satisfactorily 
proceeding,  it  will  be  advisable  to  correct  the  disordered  state  by 
a  few  grains  of  bicarbonate  of  soda  and  rhubarb,  or  sulphate  of 
potash  and  rhubarb  (Form.  8-1).  It  is  sometimes  necessary  to 
give  a  grain  or  half  a  grain  of  calomel,  or  two  or  three  grains  of 
gray  powder.  In  this  way  the  slimy  or  pasty  motions  will  be 
altered,  and  the  evacuations  be  rendered  more  natural  and  healthy. 
Some  caution  is  required  not  to  mistake  the  whitish  motions 
caused  by  undigested  milk  for  the  absence  of  bile.  Mercurials 
and  alteratives,  if  prescribed,  would  do  an  infinity  of  harm,  and 
we  should  trust  in  such  cases  to  giving  milk  in  smaller  quantities 
or   with   limewater,  and   such    simple   remedies   as  will   correct 


682  DISEASES    OF    CHILDREN. 

flatulence  and  acidity,  or  we  must  even  suspend  the  milk  altogether 
for  a  time,  and  substitute  weak  beef  tea  and  barley-water. 

If  diarrhoea  should  be  troublesome,  a  drop  of  laudanum  with  an 
alkaline  and  bismuth  mixture  will  be  very  useful  (Form.  25). 

When  there  is  sickness,  high-colored  urine,  and  mental  irrita- 
bility, bromide  of  potassium,  with  sal  volatile  and  citrate  of 
potash,  will  be  useful  followed  by  quinine  in  small  doses ;  and 
later  on  the  citrate  of  iron  and  quinine,  the  ammonio-citrate  of 
iron,  the  solution  of  dialyzed  iron  (liquor  ferri  dialysati)  or  the 
syrup  of  the  phosphate  of  iron,  or  Parrish's  Chemical  Food. 

"Steel  wine,  though  it  contains  very  little  iron,  is  extremely 
useful.  I  think  it  one  of  the  very  best  forms  for  administering 
iron  to  rickety  children.  A  teaspoonful  or  two  of  steel  with  half 
a  grain  of  quinine,  and  a  drop  or  two  of  dilute  sulphuric  acid,  con- 
stitutes a  capital  mixture  for  such  cases.  It  should  be  taken  just 
before  meals."*  I  have  found  this  preparation  of  iron  very 
serviceable  when  combined  with  arsenic  in  the  formula  recom- 
mended by  Mr.  Erasmus  Wilson. t  Arsenic  promotes  appetite 
and  increases  the  tone  of  the  digestive  functions ;  moreover, 
according  to  Ringer,  it  is  of  service  in  chronic  dyspepsia  and 
diarrhoea,  where  the  motions  contain  undigested  food.:}: 

But  cod-liver  oil  is  our  chief  remedy  in  this  disease,  and  it  has 
taken  the  place  of  almost  every  other.  It  should  be  prescribed,  as 
early  as  possible,  there  being  scarcely  any  complication  which 
prevents  its  administration.  Cough  and  diarrhoea  yield  to  it,  and 
the  secretions  improve  under  its  steady  continuance.  It  should 
be  given  in  milk,  orange  wine,  or  orange  juice,  twice  a  day,  after 
food.  I  am  satisfied  with  half  an  ounce  in  the  course  of  twenty- 
four  hours,  and  I  never  exceed  this  quantity.  Dr.  JSTorman  Moore 
mentions  the  fact  that  some  beagle  pups,  fed  on  dog  biscuits,  soon 
after  birth  were  noticed  to  have  their  legs  bent,  their  joints  en- 

*  On  Rickets,  by  Sir  W.  Jenner,  B;irt ,  op.  cit.,  p.  467. 
f  Formula  93 : 

R.    Vin.  ferri, ^iss. 

Syr.  tolut.,  .         . 3iij 

Liq.  fowleri, ,^j 

Aqnam  ad .^iv. — M. 

A  teaspoonful  in  a  tablespoonful  of  water  twice  a  day  after  food.  For  a  child  from 
five  to  ten  years  of  age. 

X  Handbook  of  Therapeutics,  4th  edit.,  p.  253. 


EICKETS   OR   RACHITIS.  683 

larged,  and  their  ribs  beaded,  but  under  cod-liver  oil  they  soon 
ceased  to  show  any  signs  of  rickets.* 

Cough  must  be  treated  in  accordance  with  the  pulmonary 
complication  that  is  present.  Depressing  drugs,  like  antimony 
and  mercury,  are  never  justifiable  for  the  bronchitis  and  pneu- 
monia of  rickety  subjects,  but  in  place  of  them,  ipecacuanha, 
carbonate  of  ammonia,  citrate  of  potash,  and  senega  should  be 
given. 

If  laryngismus  should  arise  (and  the  association  is  not  uncom- 
mon), then  iron,  cod-liver  oil,  and  bromide  of  potassium  will  be 
useful,  and  nutritious  food  and  fresh  air  will  be  equally  impor- 
tant. It  is  in  these  cases,  especially  if  the  child  remains  delicate, 
that  sea-air,  or  even  sea-bathing,  is  so  valuable  ;  Yarmouth  or 
Lowestoft  in  the  summer  ;  Clifton,  Eastbourne,  or  the  Isle  of 
Wight  in  the  winter  may  effect  a  more  rapid  improvement  than 
any  drugs. 

In  many  cases,  the  inuction  of  cod-liver  oil,  olive  oil,  or  neats- 
foot  oil  is  very  useful. 

Where  the  deformity  of  the  joints  and  bones  is  great  the  child 
should  be  prevented  from  walking,  and  properly  adapted  splints 
employed.  A  bandage,  worn  around  the  lower  ribs  and  abdomen, 
gives  great  support  to  the  weakened  muscles.  In  the  case  of 
female  children  afflicted  with  rickets,  particular  care  must  be 
taken  to  keep  them  oft'  their  feet,  until  some  suitable  appa- 
ratus has  been  applied,  so  as  to  avoid  the  characteristic  deform- 
ity of  the  pelvis,  which  would  expose  them  to  great  dangers 
should  they  live  to  bear  children.  These  deformities  consist  in 
a  diminution  in  the  antero-posterior  diameter,  due  to  the  sacrum 
and  lower  lumbar  vertebrpe  projecting  too  far  forward,  and  to  a 
further  narrowing  of  the  inlet  from  the  approximation  of  the  ace- 
tabula. 


The  Cause  and  Treatment  of  Rickets,  1876,  p.  32. 


684  DISEASES   OF   CHILDREN. 


CHAPTER   L. 

SYPHILIS   IN   CHILDREN. 

Hereditary  Syphilis  :  Its  source — Rarity  in  the  upper  classes — Frequency  in  the  lower 
classes — Quite  distinct  from  acquired  syphilis  in  children — Symptoms— External,  well 
marked  and  well  known — Internal,  less  constant — Dr.  Coupland's  remarkable  case  of 
hereditary  visceral  syphilis — Enlargement  of  the  spleen — Later  symptoms  of  hereditary 
syphilis^ Malformed  teeth — Interstitial  keratitis.  Primary  Syphilis  through  direct 
infection — Through  vaccination.  Diagnosis  and  Prognosis.  Treatment: 
Mercury  the  only  reliable  remedy — Mercurial  inunction —  Oood  feeding  important  during 
the  administration  of  mercury — Iodide  of  potassium.  Vaginal  Discharges  in  female 
children — Diagnosis  from  gonorrhoea,  with  which  it  is  so  often  confounded  by  parents — 
Its  relation  to  debility  and  the  strumous  diathesis — Treatment. 

One  of  the  saddest  facts  revealed  by  medical  and  surgical  re- 
search is  the  transmission  of  syphilis  from  a  parent  to  an  innocent 
child.  However  clear  may  be  the  origin  of  the  disorder,  what- 
ever form  the  disease  raaj  assume  in  the  father  or  mother,  it  is 
now  well  known  that  in  infancy  it  appears  in  a  distinct  character, 
differing  from  what  may  be  termed  the  adult  variety  in  many 
points  ;  though  it  is  only  of  late  j^ears  that  infantile  syphilis  has 
been  thoroughly  investigated. 

The  manner  in  which  syphilis  is  transmitted  to  a  child  is  obvious ; 
and  it  is  now  admitted  that  a  syphilitic  father  may  beget  an  in- 
fected foetus,  which  infects  the  mother.  Hence  healthy  women 
may  give  birth  to  syphilitic  children,  and  they  may  suffer  from 
secondary  symptoms,  even  though  they  have  never  had  the  disease 
in  its  primary  form.  Inoculation  of  the  mother  through  the  foetus 
has  been  experimentally  proved  by  Mr.  Savory.  But,  of  course, 
direct  infection  from  the  mother  is  equally  possible,  audit  is  prob- 
ably the  ordinary  mode  by  which  an  embryo  is  syphilized. 

In  constitutional  syphilis  the  child  becomes  infected  through  the 
vitiated  blood  of  the  parents,  or  the  semen  of  the  father.  The 
sj-mptoms  that  ensue  are  altogether  different  from  those  which 
follow  secondary  syphilis  in  the  adult. 

Hereditary  syphilis  is  very  rare  in  the  upper  classes,  even  among 
the  children  of  men  who  have  been  avowedly  profligate  before 
marriage,  and  who  admit  that  they  have  suffered  from  syphilis. 
Careful  attention  to  medical  advice,  and  good  feeding  help  to 
eradicate  the  disease,  or  to  destroy  its  property  of  transmission. 


SYPPIILIS    IN    CHILDREN.  685 

The  disease  must  be  distinguished  from  the  primary  form  which 
a  child  may  contract  from  a  diseased  nurse,  or  in  vaccination. 

Women  affected  with  secondary  syphilis  are  very  liable  to  mis- 
carriage ;  but  some  surgeons,  defective  in  gynaecological  knowl- 
edge, are  too  apt  to  attribute  abortion  to  the  existence  of  syphilis. 
Still,  when  a  child  presents  signs  of  the  disease,  a  history  of  fre- 
quent abortions  in  its  mother  is  significant. 

Intrauterine  syphilis  may,  and  frequently  does,  kill  the  foetus, 
or  the  child  may  be  born  alive  with  symptoms  of  the  disease. 
But,  strange  to  saj-,  as  a  rule,  the  disorder  does  not  manifest  itself 
till  nearly  a  month  or  six  weeks  after  birth.*  At  this  period  the 
child,  previously  well  nourished,  begins  to  lose  flesh  and  is  affected 
by  constant  snuffling,  due  to  some  morbid  change  in  the  mucous 
membrane  of  the  nasal  fossse.  This  symptom  becomes  very  trouble- 
some and  seldom  fails  to  attract  the  attention  of  the  child's  nurse 
and  mother.  The  "  snuffles  "  is  a  name  in  common  use  for  the 
complaint.  It  signifles  a  kind  of  coryza,  a  discharge  from  the  nose 
of  a  semi-purulent,  or  sanguineous  nature,  which  in  some  cases 
blocks  up  the  nostrils  and  prevents  the  child  from  sucking.  This 
is  a  ver}^  grave  condition.  The  patient  is  now  found  to  be  covered 
with  a  dull  red  eruption  in  large  patches.  The  spots  are  of  a 
coppery  hue  on  the  skin,  though  sometimes  bright,  resembling 
roseola.  Large  leprous  patches,  inclined  to  be  dry  and  scaly,  may 
be  often  seen  at  the  outer  and  upper  parts  of  the  thighs,  and  ragged 
ulcers  and  condylomata  extending  in  males  from  the  base  of  the 
scrotum  to  the  anus.  There  are  fissures  at  the  bend  of  the  joints, 
mucous  patches  of  redness,  pemphigus,  and  even  ulcerative  ecthyma 
in  some  instances  where  the  taint  is  severe.  Large  ulcers  are 
sometimes  seen  on  the  buttocks  and  inside  of  the  nostrils  in  severe 
cases,  and  superficial  ulceration  is  often  present  on  the  fingers  and 
toes.  Ulcers  or  patches  of  ulceration  often  form  on  the  mucous 
membrane  of  the  mouth  and  the  angles  are  often  fissured.  In  a 
few  w^eeks  the  child  becomes  thin,  its  skin  appears  deeply  wrinkled, 
and  of  a  dirty  soot  color  where  not  covered  by  the  eruption.    The 

*  Out  of  158  cases  collected  by  Diday,  131  children  presented  symptoms  before  the 
end  of  the  second  month,  110  had  symptoms  before  the  end  of  six  weeks,  and  86  before 
the  end  of  the  first  month.  He  concludes:  "  1.  That  the  greater  proportion  of  out- 
breaks of  constitutional  syphilis  in  newborn  children  occur  before  the  completion  of 
the  first  month  of  their  existence.  2.  That  when  the  third  month  is  once  past  there 
is  no  longer  much  probability  that  any  symptoms  of  tliis  kind  will  manifest  them- 
selves."— Infantile  Syphilis,  p.  102. 


686  DISEASES   OF    CHILDREN. 

color  has  been  said  to  resemble  that  of  coffee  mixed  witb  milk, 
and  this  is  most  apparent  in  the  face  and  forehead.  These  chil- 
dren have  "  the  look  of  little  okl  men."*  The  hair  is  scanty,  the 
eyebrows  and  eyelashes  being  often  absent ;  the  child  is  aiiected 
with  "  a  peculiarly  hoarse  cry,"  or  a  modification  of  the  voice  not 
unlike  the  changed  voice  of  syphilis  in  the  adult.  He  is  restless 
and  fretful,  and  cannot  obtain  sleep,  particularly  at  night,  because 
the  pains  are  then  more  severe. 

Vaccination  frequently  brings  out  a  specific  rash  in  children 
congeni tally  syphilitic,  who  may  not  have  exhibited  before  that 
period  any  evidence  of  the  taint.  A  very  general  rash  of  char- 
acteristic form  and  hue  may  show  itself  as  early  as  the  fourth 
day  after  the  act  of  vaccination.  This  at  once  demonstrates  that 
the  taint  was  not  conveyed  in  the  vaccine  lymph  emplo}  ed. 

An  infant  in  this  condition  is  well  known  to  all  medical  men 
who  attend  out-patient  practice  at  a  London  hospital.  The  little 
sufferer  seldom,  if  ever,  fails  to  exhibit  the  characteristic  external 
appearances  of  this  disease.  The  syphilitic  affection  can  readily 
be  distinguished  from  any  other  form  of  marasmus ;  the  snufiliug 
and  wasting  always  predominate  at  first  over  symptoms  of  in- 
ternal derangement.  The  disease  may  be  followed,  but  is  not 
usually  preceded,  by  vomiting  or  irregular  action  of  the  bowels. 
When,  however,  syphilis  is  suspected,  but  there  is  no  marked  rash, 
mucous  tubercles  may  often  be  detected  around  the  anus  and 
pudenda,  and  desquamation  of  the  palmar  and  plantar  cuticle 
generally  exists,  or  scales  like  those  in  psoriasis  and  lepra  peel  off 
the  hands  and  feet.  One  of  the  most  absolutely  pathognomonic 
evidences  of  congenital  syphilis  is  a  coppery  blush  extending  from 
the  anus  to  the  nates  ;  it  is  found  only  during  the  early  months  of 
infantile  life. 

We  have  been  speaking  of  the  external  symptoms  of  hereditary 
syphilis.  The  next  question  that  naturally  suggests  itself  is :  what 
internal  lesions  occur  in  this  malady  ?  But  this  question  is  hard 
to  answer,  for  visceral  symptoms  are  seldom  well  marked  in  these 
cases.  Mr.  Holmes,  after  describing  the  well-known  external 
signs  of  hereditary  syphilis,  remarks :  "  Finally,  certain  lesions 
or  degenerations  of  the  principal  viscera  have  been  pointed  out 
as  peculiar  to  congenital  syphilis  ;  but  I  cannot  say  that  the  evi- 
dence on  this  subject  appears  to  me  very  conclusive,  at  any  rate, 

*  Diday,  op.  cit.,  p.  86. 


SYPHILIS   IF    CHILDREN.  687 

these  lesions  are  of  little  moment  in  practice,  inasmuch  as  no 
means  exist  of  recoo-nizino;  them  before  death. "'^ 

Diday  admits  the  difficulty  of  recognizing  the  syphilitic  changes. 
Sometimes  the  enlarged  and  indurated  liver  may  be  felt  through 
the  thin  parietes,  and  peritoneal  effusion,  anasarca,  and  other 
symptoms  indicating  obstruction  to  the  circulation  through  the 
organ  have  occurred ;  but  neither,  according  to  his  experience, 
nor  that  of  Gubler,  whom  he  quotes,  has  jaundice  in  any  instance 
been  seen.f  A  most  interesting  case,  showing  to  what  extent  the 
viscera  may  be  implicated  in  this  disease,  even  in  an  infant  of 
three  months,  has  been  described  by  Dr.  Conpland.:};  It  must  be 
remarked,  however,  that  the  sole  evidence  of  syphilis  rested  On 
the  fact  that  the  child's  mother  had  been  live  times  pregnant  ;  the 
first  born  alone  surviving.  Two  children  were  still-born,  once  the 
mother  miscarried,  but  the  fifth  confinement  resulted  in  the  birth 
of  the  patient,  who  "  had  been  to  all  appearances  healthy  to  within 
three  hoars  of  its  death,  when  it  began  to  suffer  from  shortness 
of  breath."  The  visceral  lesions  were  those  seen  in  tertiary  forms 
of  syphilis  among  adults.  Large  gummata  were  found  in  the 
liver,  and  a  small  gummatous  nodule  was  detected  in  the  right 
lung.  The  cortical  portion  of  the  kidneys  and  the  walls  of  the 
heart  were  infiltrated  with  small  round  cells.  The  singular 
cardiac  complication  accounts  for  the  sudden  death  of  the  pa- 
tient. 

Dr.  Gee  observes  that  the  spleen  is  much  enlarged  in  about  one- 
fourth  of  the  cases  of  hereditary  syphilis,  and  that  sometimes 
enlargement  of  the  liver  and  lymphatic  glands  is  superadded. § 
Whether  the  relation  will  hold  generally  good  may  admit  of  some 
doubt,  because  it  may  possibly  arise  from  the  cachectic  condition 
of  the  system  attendant  upon  the  syphilitic  infection.  Still,  there 
can  be  no  doubt  of  the  frequent  association.  Wilks  and  Moxon 
say  :  "  In  syphilis  we  often  meet  with  hypertrophic  enlargement 
of  the  spleen. "li 

An  infant  afflicted  with  -hereditary  syphilis  is  remarkably  amen- 
able to  treatment,  the  more  so  because  mercury  is  not  liable  to  act 

*  System  of  Surgery,  art.  Surgical  Diseases  of  Childhood. 
f  Diday  on  Infantile  Syphilis,  New  Sydenham  Society,  1 659,  p.  94. 
X  Trans.  Path.  Soc,  vol.  xxvii,  p.  303. 

§  On  Enlargement  of  the  Spleen  in  Hereditary  Syphilis,  and  in  some  other  Diseases 
of  Children,  Koy.  Med.  and  Chir.  Soc,  Lancet,  April  13th,  1867. 
II  Pathological  Anatomy,  by  Wilks  and  Moxon,  1875,  p.  475. 


688  DISEASES    OF    CHILDREN. 

prejudicially  on  very  young  subjects,  on  wlaom  it  exercises  its  anti- 
syphilitic  tendencies  as  well  as  on  the  adult.  But  the  mortality 
among  syphilitic  children  is  known  to  be  high.  As  they  grow  older, 
if  they  survive,  several  fresh  symptoms  develop  themselves.  The 
milk  teeth  are  brittle,  and  very  prone  to  caries,  ■  The  permanent 
canines  and  incisors  develop  very  characteristic  peculiarities,  first 
pointed  out  by  Mr.  Hutchinson.  The  upper  middle  incisors  are 
the  most  characteristic  in  these  cases.  They  are  smaller  than 
usual,  wide  apart,  and  their  edges  are  deeply  crescentic.  When 
first  cut  small  friable  tubercles  project  from  the  crescentic  borders, 
but  these  are  soon  broken  ofif.  Deafness,  both  from  disease  of  the 
tympanum  and  afiections  of  the  labyrinth,  is  frequent  among 
syphilitic  children.  Another  symptom,  also  first  detected  by  Mr. 
Hutchinson,  is  a  disease  of  the  cornea,  termed  "  interstitial  kera- 
titis" This  disorder  is  almost  always  accompanied  by  the  charac- 
teristic deformity  of  the  teeth.  It  appears  after  the  fifth  year. 
The  cornea  becomes  uniformly  hazy,  with  a  few  interspersed 
whitish  dots  ;  it  is  found  to  be  also  singularly  vascular.  Accord- 
ing to  Mr.  Holmes,  iritis  is  a  rare  symptom  of  infantile  syj)hilis.* 
There  are  also  to  be  noticed  some  prominence  of  the  forehead, 
flattening  of  the  bridge  of  the  nose,  linear  cicatrices  at  the  angles 
of  the  mouth,  and  the  palate  presenting  the  form  of  the  Gothic 
arch. 

Primary  chancres  occurring  on  the  genitals  of  children  from 
direct  infection  through  brutal  outrage,  or  early  depravity,  do  not 
differ  from  the  same  sores  seen  in  adults.  They  are  of  interest 
from  a  medico-legal  point  of  view.  Where  a  sore  exists  on  the 
genitals  at  the  time  of  parturition,  a  child  may  become  infected, 
but  it  is  exceedingly  rare,  and  the  evidence  furnished  on  this  point 
is  by  no  means  conclusive. 

Infection  from  the  nipples  of  diseased  nurses,  produces  in  child- 
hood the  symptoms  of  primary,  followed  by  secondary  syphilis, 
without  the  distinguishing  features  of  the  hereditary  type  of  the 
disease.! 
.Lastly,  syphilis  may  be  communicated  through  vaccination,  a 

*  Surgiciil  Treatment  of  Children's  Diseases,  1878,  p.  351. 

f  In  tlie  tenth  volume  of  the  Clin.  Soc.  Trans.,  will  be  found  a  remarkable  case  re- 
corded by  Dr.  Dowse.  A  girl,  ten  years  of  age,  contracted  syphilis  from  an  infant  she 
was  nursing,  through  a  slight  abrasion  on  her  forearm.  The  disease  was  very  severe, 
and  proved  fatal. 


--SYPHILIS   IX   CHILDREN.  689 

chancre  appearing  at  the  point,  touched  by  virus  from  a  syphilitic 
subject.  Of  course,  this  terrible  complication  suggests  great  caution 
in  guaranteeing  the  purity  of  lymph,  as  insisted  on  b}^  Mr.  Henry- 
Lee.  It  must  be  taken  from  the  vesicles  not  later  than  the  eighth 
day,  unmixed  with  blood,  or  an}'  other  secretion.  Of  the  manner 
in  which  syphilis  is  propagated  by  vaccination,  it  is  recorded.  "  that 
in  a  district  of  Piedmont,  in  the  year  1861,  where  syphilis,  if  not 
nnknown,  was  at  any  rate  so  rare  that  the  medical  men  in  the 
neighborhood  had  no  opportunity  of  seeing  it,  forty-six  children, 
of  various  ages,  were  simultaneously  attacked  with  well-marked 
syphilis,  proceeding  in  all  the  cases  which  could  be  properly 
examined,  from  chancres  in  the  arms,  followed  by  buboes  in  the 
axilla ;  and  that  all  these  children  had  been  vaccinated,  directly  or 
indirectly,  from  a  single  child,  who  was  subsequently  proved  to 
have  contracted  syphilis  from  a  wet-nurse  ;  and,  further,  that  these 
children  transmitted  the  same  disease  to  a  number  of  children, 
their  wet-nurses,  mothers,  etc.,  and  even  to  children  who  nursed 
and  played  with  them ;  that  the  women  so  infected,  in  turn  in- 
fected their  husbands;  and  finally  that  the  disease  yielded  in  all 
cases  to  the  usual  remedies  for  syphilis."*  Several  similar  cases 
are  recorded. 

Diagnosis. — The  general  history  of  the  case,  the  "  snuffles,"-  the 
eruption  of  the  skin,  and  the  sallow  parchment-like  hue  of  the 
countenance,  distinguish  it  from  all  other  diseases.  There  is  not 
much  fear  of  confounding  noma  pudendi  with  venereal  phagedena, 
though  dishonest  parents  might  falsely  give  a  syphilitic  history  to 
the  former  complaint. 

In  respect  to  prognosis,  many  syphilitic  children  fall  into  such  a 
bad  state  of  health  that  they  slowly  waste  and  die.  When  the 
nose  is  obstructed  by  mucus  in  infants,  so  that  they  are  unable  to 
suck,  the  complaint  often  proves  fatal.  Then,  too,  if  a  child  is 
attacked  with  an  inflammatory  or  eruptive  disease,  or  even  a  mild 
form  of  diarrhoea,  it  is  prone  to  succumb  from  exhaustion. 

Treatment. — Mercury  is  an  invaluable  remedy  in  congenital 
syphilis,  and  without  it  there  is  no  probability  of  eradicating  the 
disease.  It  should  be  employed  in  everj^  case,  and  if  there  be  any 
doubt  in  diagnosis  it  should  not  even  then  be  withheld.  Every 
night  and  morning  a  grain  or  two  of  the  Hyd.  c.  Greta  should  be 

*  Surgical  Treatment  of  Children's  Diseases,  by  T.  Holmes,  1868,  p.  353. 

44 


690  DISEASES    OF    CHILDREN. 

given,  to  which  a  little  Pulv.  Cretse  Arom.  c.  Opio  must  be  added, 
if  the  bowels  are  inclined  to  be  loose ;  or  what  is  preferable,  the 
Pulv.  Ipecac,  co.  Children  during  the  time  they  are  under  a 
mercurial  course  ought  to  be  well  fed,  otherwise  th6  prejudicial 
effects  of  mercury  upon  nutrition  are  apt  to  be  manifested. 

The  tincture  of  bark  and  small  doses  of  the  perchloride  of  mer- 
cury form  a  good  combination  when  there  is  considerable  debility 
and  cachexia.  Mercurial  inunction  has  some  very  warm  advocates, 
and  among  them  the  late  Sir  B.  Brodie,  w^ho  contended  that  mer- 
cur}',  internally  administered,  seldom  cured  the  patient,  whilst 
externally  applied,  he  had  never  known  it  to  fail.  It  simply  con- 
sists in  smearing  about  a  drachm  of  the  Ung.  Hj^drargyri  on  a 
piece  of  flaimel  every  night,  and  applying  it  round  the  thighs  or 
arms  for  the  usual  period  of  treatment,  viz.,  six  weeks.  The  child 
must  be  well  washed  before  every  fresh  inunction,  otherwise 
troublesome  rashes  are  liable  to  appear  at  the  seat  of  application.* 

Iodide  of  potassium  is  seldom  necessary,  for  most  cases  are 
readily  and  thoroughly  cured  by  mercurials,  still  that  salt  has 
been  used  with  excellent  effect.  This  drug  has  cured  obstinate 
ulcers  about  the  tongue  and  fauces  in  children  affected  with  heredi- 
tary sj'philis.  In  "interstitial  keratitis"  the  use  of  iodide  of  po- 
tassium is  advisable.  When  the  syphilitic  taint  has  disappeared, 
and  debility  is  the  chief  symptom  to  contend  with,  the  syrup  of 
the  iodide  of  iron  is  an  excellent  remedy.  Cod-liver  oil  is  some- 
times of  great  service,  given  in  small  doses,  with  milk  and  lime- 
water. 

When  the  nostrils  are  obstructed,  they  may  be  syringed  out 
with  warm  water  twice  a  day,  and  in  some  cases  a  mild  astringent 
lotion  is  useful;  but  the  influence  of  mercurj^  is  generally  suffi- 
cient, and  is  most  to  be  relied  upon. 

For  the  ulcerations  that  form  on  the  body  and  about  the  anus, 
zinc  ointment,  a  lotion  of  carbolic  acid  (1  in  60),  or  the  black  wash 
will  be  found  useful.  Of  greater  service  still  is  an  application  com- 
posed of  oxide  of  zinc  and  starch,  with  a  fourth  part  of  calomel. 

*  "  A  late  discussion  in  the  Lyons  Medical  Society  disclosed  the  fact  that  the  fol- 
lowing opinions  were  held  by  members :  1.  Healthy  children  can  be  procreated  by 
diseased  parents  in  the  intervals  of  syphilitic  recrudescence.  2.  The  syphilitic  mother 
slionld  always  be  made  to  suckle  her  child.  3.  Mercurial  treatment  of  the  mother 
during  pregnancy  may  give  rise  to  an  abortion,  apart  from  the  constitutional  disease. 
Mercurial  treatment  at  sucJi  times  is  best  conducted  by  the  process  of  inunction." — 
The  American  Practiiioner,  Feb.  1880,  p.  115. 


SYPHILIS    IN    CHILDREN.  691 

The  diet  should  consist  of  a  liberal  allowance  of  milk,  and  the 
child  should  have  free  access  to  pure  air. 

Up  to  the  period  of  the  second  dentition,  conditions  of  ansemia 
in  the  subjects  of  congenital  syphilis  are  not  improved  by  iron, 
unless  it  be  combined  with  mercury. 

Vaginal  discharges  of  a  muco-purulent  character  are  frequently 
observed  in  female  children  who  are  delicate,  and  of  a  strumous 
habit.  The  complaint  occurs  during  dentition,  from  intestinal 
irritation,  ascarides  in  the  rectum,  and  after  scarlatina  and  other 
fevers.  These  discharges  are  almost  invariably  attributed  by 
parents  to  some  specific  taint,  and  they  sometimes  imagine  the  child 
has  been  brutally  treated.  The  symptoms  are  much  less  severe 
than  in  gonorrhoea.  The  complaint  occurs  in  children  of  a  few 
months  old,  though  it  is  more  often  observed  in  those  of  six  or 
seven  years  of  age.  The  disease  is  obstinate  in  character,  and 
may  persist  in  spite  of  cleanliness  and  the  most  careful  treatment. 

The  symptoms  are  redness  of  the  vulva,  and  the  lower  part  of 
the  vagina,  as  may  be  seen  on  separating. the  labia.  A  thick  muco- 
purulent discharge  issues  from  the  vagina,  and  the  source  of  the 
disease  is  higher  up  than  is  generally  imagined.  Sometimes  there 
is  no  local  discomfort,  but  if  the  discharge  has  been  of  any  con- 
siderable duration,  then  the  parts  are  sore  and  there  is  pain  during 
micturition. 

The  treatment  best  adapted  to  cure  the  complaint  is  to  well 
foment  the  parts,  night  and  morning,  w^ith  warm  water.  When 
there  is  much  local  irritation  and  redness  it  should  be  continued 
till  relief  follows.  Sitting  the  child  for  a  few  minutes  in  a  hip- 
bath before  going  to  bed  is  soothing  and  comfortable.  After  this 
a  lead  lotion  should  be  applied  twice  or  three  times  a  day.  The 
child  should  not  be  permitted  to  run  about  till  a  piece  of  cotton 
wool,  well  spread  out,  has  been  laid  between  the  labia,  so  that  the 
contiguous  sides  do  not  approximate.  The  discharge  is  then 
soaked  up  by  the  wool  instead  of  trickling  around  the  perinseum 
and  adjoining  parts,  which  increases  the  irritation.  When  the  in- 
flammation has  subsided,  an  astringent  injection  of  alum  and  zinc 
may  be  employed,  and  if  the  disease  should  prove  rebellious  to 
treatment,  a  nitrate  of  silver  lotion  maybe  substituted,  and  tonics, 
cod-liver  oil,  and  sea-air  will  be  advisable. 


692  DISEASES   OF  CHILDEEIir, 

CHAPTER    LI. 

ANEMIA. 

Deftnitiok  of — Division  into.  1.  Active  Anjejiia:  Sympicms — Causes — Treaf- 
ment.  2.  Chkonic  Anemia  :  Causes — General  and  physical  signs — "  Humming- 
top  sound,"  how  produced — Effect  of  pressure  with  the  stethoscope  in  ina-easing  or 
diminishing  the  intensity  of  arterial  and  venous  murmurs — Case  in  illustration — Death 
sometimes  results  from  deterioration  of  the  blood  alone,  without  any  organic  change — In 
some  cases  there  is  fatty  degeneration  of  the  heart.  Treatment  :  Importance  of  rest 
if  the  heart  is  feeble — Preparation  of  iron,  especially  the  ammonio- citrate  of  iron — Syrup 
of  hypophosphite  of  iron — Iron  lozenges — Belladonna — Schvxdhach  ivatei — Change  of 
air.  Idiopathic  Anjemia  ;  Enlargement  of  the  cervical  lymphatic  glands.  Lympha- 
DENOMA  {Modgkin's  disease — Adenie  Trousseau — Ancemia  lymphatica) :  Leucocy- 
themia. 

The  composition  of  the  blood  is  perpetually  undergoing  altera- 
tions, due  to  differences  in  the  nature  and  quality  of  the  food  that 
is  consumed,  and  to  the  changes  that  ensue  in  the  functions  of 
assimilation  and  digestion.  Liable,  then,  as  this  fluid  is  to  altera- 
tion, it  may  abound  or  be  deficient  in  one  or  more  of  its  elements. 
There  may  be  an  excess  of  blood  [hypercemia)  or  a  deficiency  of 
blood  [ancemia).  It  is  with  the  latter  condition  that  we  have  now 
to  deal. 

Anaemia  or  span?emia  may  be  defined  as  a  state  of  the  system 
arising.  L  From  deficiency  of  the  volume  of  blood  itself.  2. 
From  a  deficiency  of  the  red  corpuscles  in  the  blood.  Other  solid 
constituents  of  the  circulating  fluid  may  be  also  more  or  less  de- 
ficient, and  the  proportion  of  water  increased.  This  morbid  state 
occurs  sufiiciently  often  among  children  to  justify  special  notice. 
It  may  be  termed  "  simple  ancemia  "  or  bloodlessness,  there  being 
in  other  respects  no  actual  disease. 

Anfemia  may  be  divided  into.  1.  Active  or  acute  ancemia.,  where 
the  volume  of  the  blood  is  lessened,  2.  Chronic  ancemia,  where  the 
red  and  white  corpuscles  are  deficient,  as  well  as  the  solid  con- 
stituents of  the  blood  in  general. 

1.  Acute  anaemia  is  the  condition  which  results  from  violent 
epistaxis,  or  when  severe  hgemorrhage  occurs  from  wounds,  ulcers, 
mucous  membranes,  or  internal  organs  ;  or  it  supervenes  in  the 
course  of  an  acute  disease. 

2.  Chronic  anaemia  comes  on  more  gradually  from  insufiicient 
food  and  starvation.     We  have  examples  of  special  forms  of  the 


ANEMIA.  693 

aiFection  where  tbe  blood  is  deteriorated  from  lono;-standino;;  de- 
bility,  general  exhaustion,  fevers,  albuminuria,  tuberculosis,  etc. 

The  symptoms  of  the  acute  form  are  those  of  syncope,  the  weak- 
ened heart  being  insufficiently  stimulated  to  action  by  the  dimin- 
ished quantity  of  blood  pressing  through  its  cavities.  There  is 
extreme  pallor  of  the  face,  feeble  or  suspended  respiration,  cold 
clammy  skin,  and  a  small  feeble  pulse.  After  a  time  the  patient 
may  show  signs  of  rallying,  and  the  features  assume  a  brighter 
look  ;  the  skin  becomes  warmer,  the  j)ulse  returns,  he  stares  about 
as  if  in  bewilderment,  and  sighs  deeply,  or  is  sick.  If  he  attempt 
to  walk  before  reaction  is  re-established  the  faintness  returns,  and 
in  grave  cases  where  the  hfernorrhage  has  been  profuse,  the  face 
becomes  paler  and  more  ghastly,  the  extremities  are  cold,  and  the 
pulse  cannot  be  felt.  The  patient  is  incessantly  restless,  tossing 
about  in  bed  from  one  side  to  the  other,  unable  to  swallow,  and 
incapable  of  being  roused.  Convulsions  ensue,  followed  by  coma 
and  death  if  the  loss  of  blood  continue.  After  death,  in  these 
cases,  the  cavities  of  the  heart  are  found  empty,  and  the  lungs  and 
internal  viscera  are  pale. 

The  treatment  consists  in  placing  the  patient  in  a  recumbent 
posture,  with  the  head  low,  as  in  the  management  of  syncope ; 
and  in  endeavoring  to  restore  the  warmth  of  the  surface  by  friction, 
and  the  internal  use  of  stimulants,  such  as  wine,  brandy,  or  am- 
monia, if  the  patient  can  swallow.  A  mustard  poultice  applied 
over  the  cardiac  region  and  to  the  calves  of  the  legs  will  be  some- 
times necessary.  To  moderate  nervous  excitement,  and  to  subdue 
restlessness  and  delirium,  opium  may  be  needed,  either  in  one  full 
dose  or  in  smaller  doses,  repeated  according  to  the  discretion  of 
the  practitioner.  Where  the  patient  is  unable  to  swallow,  brandy 
or  beef  tea  may  be  thrown  into  the  rectum. 

Simj)le  chronic  ancemia  may  result  from  the  acute  condition  which 
has  preceded  it,  or  it  steals  on  gradually  from  chronic  diarrhoea, 
scanty  food,  and  a  deficiency  of  light  and  air.  When  children  are 
confined  to  unhealthy  dwellings,  which  abound  in  London  and 
large  towns  in  general,  they  often  present  a  striking  contrast  to 
those  who  are  reared  in  the  pure  air  of  the  country.  A  condition 
of  chronic  ansemia  is  often  observed  in  children  who  are  naturally 
delicate,  or  who,  after  being  reared  in  the  country  for  the  first  few 
years  of  their  lives,  are  transferred  to  London  or  some  other  large 
city,  and  are  placed  at  school  in  crowded  rooms,  and  in  an  impure 


694  DISEASES    OF    CHILDREN. 

atmosphere.  In  this  variety  of  ansemia  the  blood  is  also  im- 
poverished and  deficient  in  red  corpuscles.'^ 

The  ^e?iera?  symptoms,  which  maj^  have  come  on  in  the  most 
gradual  and  imperceptible  manner,  are  great  pallor  of  the  skin, 
mucous  membranes,  gums,  and  conjunctiva.  The  ruddy  com- 
plexion of  health  has  departed,  and  the  fine  network  of  capillaries 
is  no  longer  visible.  There  is  debility,  with  exhaustion,  and  a 
tendency  to  faint  after  excitement  or  slight  illness.  The  heart  is 
agitated,  and  palpitates  on  the  least  exertion  or  excitement ;  the 
impulse  is  diffused,  and  appears  to  strike  against  the  hand  very 
suddenly,  whilst  the  apex  beat  can  often  be  recognized  outside 
the  nipple  line  ;  and  the  aortic  valve  sound  is  sharp  and  abnor- 
mally clear.  The  pulse  is  small  and  weak  from  deficiency  of 
blood,  and  exertion  or  fatigue  increases  its  frequency  at  once ;  the 
tongue  is  extremely  pallid,  and  usually  smooth,  but  in  some  cases 
it  is  slightly  furred,  flabby,  or  even  oedematous,  with  indenta- 
tions along  its  sides,  caused  by  contact  with  the  teeth.  Inter- 
costal neuralgia  and  pain  over  the  cardiac  region  are  frequently 
to  be  observed,  as  well  as  a  sense  of  heaviness  and  weight  in  the 
limbs  ;  there  is  headache,  chiefly  affecting  the  forehead  and  ver- 
tex in  many  cases. f  The  carotids  pulsate  strongl}^,  the  appetite 
is  imperfect,  the  bowels  are  torpid,  and  the  secretions  scanty. 

When  extreme  ansemia  in  children  is  attended  with  loss  of  flesh 
and  symptoms  of  general  cachexia,  there  are  grounds  for  the 
suspicion  of  tubercle,  and  very  often  disease  of  the  mesenteric 
glands,  even  in  the  absence  of  fever  and  cough.  The  bloodless 
condition  and  waxy  tint  of  these  children  encourage  the  idea  that 
some  organic  lesion  has  arisen,  and  what  so  likely  to  complicate 
the  anaemia  as  the  tubercular  dyscrasia. 

Three  kinds  of  murmurs  may  be  heard  in  anremia.  1.  Cardiac 
murmurs.     2.  Arterial  murmurs.     3.  Venous  murmurs. 

The  physical  signs  heard  over  the  cardiac  region,  and  the  great 
arteries  and  veins  of  the  neck,  are  probably  owing  to  the  normal 

*  Even  "  in  that  temperament  which  when  exaggerated  becomes  anaemic,"  as  Dr. 
Carpenter  remarks  in  his  Principles  of  Pluman  Physiology,  "  there  is  a  marked  dimi- 
nution of  the  corpuscles,  the  nuraljer  contained  in  a  cubic  centimeter  falling  from 
5,000,000,  which  is  the  normal  amount,  to  about  2,000,000."  This  reduction  affects  the 
red  corpuscles,  for  the  white  corpuscles  and  fibrin  are  unaffected  whilst  the  water  is 
increased. 

t  See  Chap.  I,  On  the  Headache  of  Cerebral  Ansemia,  On  Headaches,  by  W.  H.  Day, 
M.D.,  3d  edit.,  1880. 


ANEMIA.  695 

relations  being  destroyed  between  the  blood  and  the  muscular 
tissue  of  the  heart ;  the  former  being  thin  and  deficient  in  red 
corpuscles,  and  the  latter  having  become  flabby  and  lost  its  tone. 
The  murmurs  heard  are  "blood  sounds,"  and  do  not  actually 
owe  their  existence  to  any  obstruction  in  the  course  of  the  circu- 
lation. 

The  most  frequent  cardiac  murmur  is  that  heard  over  the  pul- 
monary artery,  coincident  with  the  heart's  systole.  It  is  soft,  of 
low  pitch,  and  localized  over  the  second  and  third  left  intercostal 
spaces,  where  the  cartilages  join  the  sternum.  The  artery,  at  its 
origin,  is  superficial,  and  near  the  sternum,  so  that  the  sound  is 
easily  heard  when  the  blood  passes  through  it.  A  deep  inspira- 
tion, which  fully  inflates  the  lung  and  elevates  the  chest- wall, 
may  cause  the  sound  to  disappear,  but  pressure  with  the  stetho- 
scope over  the  vessel,  whilst  the  patient  holds  his  breath,  will 
increase  its  intensity.  I  have  seen  two  or  three  instances  where 
the  lung  was  retracted  in  adults,  and  the  murmurs,  which  were 
loud,  disappeared  when  the  lung  was  fully  inflated  on  a  deep  in- 
spiration. 

Similar  murmurs  can  be  heard  over  any  of  the  heart's  orifices  ■ 
in  extreme  anaemia  in  children  and  delicate  persons — in  the 
course  of  the  aorta,  and  throughout  the  cardiac  area,  or  even 
the  entire  sternum,  but  they  are  generally  loudest  at  the  base  of 
the  heart,  and  are  single,  soft,  and  blowing.  This  single  mur- 
mur is  readily  transmitted  through  the  walls  of  the  heart  when 
its  muscular  tissue  is  relaxed,  and  the  blood  is  impoverished  and 
thin. 

The  hridt  de  soufflet  (bellows  murmur)  is  an  endocardial  murmur, 
and  is  usually  considered  diagnostic  of  organic  change.  AVhen 
very  soft,  and  occurring  even  at  the  apex  in  anaemic  subjects,  it 
may  be  simply  the  expression  of  debility  and  relaxation  of  the 
mitral  orifice  without  any  roughing  or  contraction  of  the  valves 
guarding  the  aperture  of  the  heart.  Although  opinions  are  not 
unanimous  on  the  mode  of  production  of  this  murmur,  it  accords 
with  my  experience  that  it  is  sometimes  heard  in  children  who 
are  anaemic,  and  whose  blood  is  so  watery  that  it  is  readily  thrown 
into  vibration  as  it  passes  along  the  vessels.  If  deterioration  in 
the  quality  of  the  blood  can  lead  to  arterial  and  venous  murmurs, 
we  are  bound  to  accept  this  as  a  reasonable  explanation  in  some 
cases. 


696  DISEASES   OF   CHILDEEjST. 

Over  the  large  arteries  in  the  neck,  and  synchronous  with  the 
pulse,  another  soft,  single,  intermittent  blowing  murmur  is  heard 
when  the  stethoscope  is  applied.  These  murmurs  are  common 
after  great  losses  of  blood,  but  no  exact  conclusions  can  be  drawn 
from  them  alone. 

In  severe  cases  of  anaemia,  where  the  blood  is  much  changed 
and  attenuated,  there  may  be  heard  over  the  jugular  veins,  just 
above  the  clavicles,  and  especially  over  the  right  jugular  vein, 
a  continuous  hum  or  "humming-top"  sound  {l^ruit  de  diable, 
as  the  French  call  it).  According  to  Dr.  Gee,  pressure  with  the 
stethoscope  will  produce  the  murmur  in  a  certain  number  of  cases, 
but  a  venous  hum  in  chlorotic  persons  is  independent  of  pressure, 
and  is  due  to  the  anatomical  relations  of  the  parts  concerned.* 
"  These  venous  murmurs  are  seldom  absent  in  well-marked  anae- 
mia ;  nevertheless,  ansemia  is  not  to  be  positively  inferred  from 
the  mere  presence  of  any  one  of  these  murmurs. "f 

When  these  symptoms  continue  for  a  long  time,  and  the  heart 
is  perpetually  agitated,  some  dilatation  of  its  walls  is  apt  to 
ensue.  Among  children,  the  heart's  area  is  frequently  increased 
without  murmur,  but  in  long-standing  cases  the  increased  im- 
pulse, which  is  sudden  and  slapping,  may  eventually  lead  to 
hypertrophy,  the  stroke  of  the  heart  after  a  time  becoming  longer 
and  heaving.  Although  this  morbid  state  is  not  so  frequent 
among  males  as  females  about  the  time  of  menstruation,  it  is 
sometimes  met  with  in  boys  who  are  brought  up  in  unhealthy 
homes,  breathe  bad  air,  and  are  deprived  of  good  food. 

The  diagnosis  of  blood-murmurs  from  those  due  to  organic 
change  may  be  briefly  summed  upas  follows.  In  the  former  case, 
as  we  have  seen,  ansemic  murmurs  are  either  arterial  or  venous  ; 
they  are  chiefly  heard  over  the  base  of  the  heart,  and  at  the  pul- 
monary^ orifice ;  and  although  we  cannot  state  positively  the 
causes  on  which  they  depend,  we  are  probably  right  in  supposing 
that  the  very  soft  character  of  the  murmur  precludes  any  likeli- 
hood of  a  roughened  or  constricted  aperture,  wdiich  is  known  to 
produce  a  rough,  grating,  musical,  or  prolonged  murmur  over  the 
situation  of  particular  valves.  The  presence  of  a  diastolic  bruit 
also  would  indicate  valvular  disease.  When  the  murmur  is  soft 
and  blowing,  and  is  diffused  over  the  entire  cardiac  region,  fading 

*  Auscultation  and  Percussion,  1877,  p.  182. 

t  The  Science  and  Practice  of  Medicine,  by  Dr.  Ailken,  vol.  ii,  p.  83,  1872. 


ANAEMIA.  697 

in  intensity  towards  the  apex,  it  is  due  to  blood  change ;  when  it 
is  localized  over  one  or  more  of  the  heart's  orifices,  and  cannot  be 
detected  above  the  third  rib,  it  is  presumably  due  to  organic 
change.  Irregular  action  of  the  heart,  feeble  pulse,  congestion  of 
the  lungs  from  regurgitation  through  the  mitral  orifice,  blueness 
of  the  fingers,  and  hypertrophy  following  rheumatism,  also  point 
to  organic  change. 

The  following  is  an  excellent  example  of  chronic  anoemia  of  a 
most  severe  type,  lasting  a  long  time  without  any  real  change  for 
better  or  worse : 

G.  W — ,  {Bt.  9,  was  admitted  into  the  Samaritan  Hospital  under 
ray  care  on  October  4th,  1877.  He  came  of  a  delicate  family,  and 
his  mother  was  highly  nervous.  The  house  in  which  he  resided 
was  said  to  be  unhealthy.  It  was  very  small,  and  situated  imme- 
diately above  stables.  He  began  to  droop  two  months  before  ad- 
mission, complaining  of  pain,  either  in  his  head,  chest,  or  side. 
The  boy  presented  on  his  admission  a  yellowish,  waxy  pallor,  with 
dark  eyelids  and  bloodless  lips,  the  gums  and  conjunctiva  were 
very  pallid,  the  pulse  was  quick  and  small,  the  temperature  was 
normal.  The  heart's  area  was  increased,  and  the  apex  beat  was 
below  and  to  the  left  of  the  nipple,  so  that  dilatation  most  proba- 
bly existed  to  some  extent.  A  soft  murmur  was  heard  over  all 
the  orifices  of  the  heart,  weakest  at  the  apex,  and  loudest  below 
the  left  clavicle.  The  murmur  was  not  audible  at  the  back.  A 
venous  hum  in  the  neck  was  very  distinct.  The  percussion  note 
was  not  so  clear  under  the  right  clavicle  as  the  left,  and  expiration 
was  longer  on  both  sides  than  in  health,  which  is  by  no  means 
uncommon  in  states  of  debility.  The  liver  was  of  full  size,  but  no 
enlarged  glands  could  be  felt  through  the  abdominal  walls,  nor  in' 
the  neck. 

A  mixture  containing  the  ammonio-citrate  of  iron  and  Fowler's 
solution  was  given  three  times  a  day,  and  eggs  and  beef  tea  pre- 
scribed as  the  patient's  diet. 

On  the  30th,  without  any  ascertainable  cause,  he  became  very 
feverish,  and  between  6  p.m.  and  12  p.m.  the  temperature  fluctu- 
ated between  102.6°  and  104.0° ;  the  pulse  reached  134 ;  the  skin 
was  burning  hot  and  dry  ;  he  complained  of  pain  in  his  abdomen, 
was  sick,  and  wandered  when  he  slept ;  next  day  the  temperature 
fell  to  100.2°  and  two  days  later  it  was  normal. 

Mr.  Alban  Doran  examined  the  blood  and  found  it  deficient  in 


698  DISEASES   OF   CHILDREISr. 

red  corpuscles,  but  the  white  corpuscles  were  not  in  excess,  nor 
were  ihej  large  nor  unusually  granular. 

On  the  15th  of  ISTovember  it  was  recorded  that  the  least  thing 
agitated  and  excited  the  patient;  he  became  sick  without  cause, 
and  a  full  meal  sent  up  his  temperature  two  or  three  degrees. 
Fifteen  minims  of  Liquor  Ferri  Dialj^zati  were  ordered  in  a  table- 
spoonful  of  water  three  times  a  day. 

On  the  23d,  the  report  states  that  his  ansemia  was  extreme,  he 
had  a  chlorotic  tint,  the  gums,  lips,  and  mucous  membrane  of  the 
mouth  and  conjunctiva  being  absolutely  colorless.  There  was  no 
confusion  of  ideas,  giddiness,  or  headache.  He  had  a  little  hack- 
ina;  couo-h,  with  some  whistling;  rhonchi  over  the  front  of  the 
chest,  but  no  dulness.  The  temperature  had  averaged  98.4°  during 
the  preceding  three  weeks.  For  some  days  he  had  been  taking 
half  a  pint  of  milk,  beef  tea,  eggs,  and  two  ounces  of  port  wine 
daily.  He  was  now  ordered  to  take  half  an  ounce  of  essence  of 
meat  three  times  a  day,  and  the  solution  of  iron  to  be  increased 
to  twenty  minims  for  a  dose. 

December  21st. — He  had  improved  in  strength  and  general  ap- 
pearance.    His  friends  took  him  home. 

Beadmitted  February  26th,  1878,  feeling  ill  with  severe  head- 
ache and  exhaustion;  temperature  103°,  pulse  128,  respiration  40. 
The  murmurs  were  louder  over  the  heart  and  cervical  vessels.  He 
had  not  lost  more  flesh.  Cold  sponging  was  ordered  to  reduce  the 
febrile  condition,  and  a  grain  of  quinine  was  given  three  times  a 
day.     In  fiv^e  days,  the  temperature  was  normal. 

March  4th. — A  phosphorus  capsule,  containing  grain  1.30,  was 
ordered  daily  after  the  midday  meal.  Orange  juice  with  milk 
was  also  prescribed. 

9th. — He  took  his  food  better,  and  the  pulse  fell  to  96,  but  he 
had  a  vitiated  appetite,  desiring  the  most  indigestible  and  un- 
wholesome articles  of  diet.  The  heart  was  less  tremulous;  the 
apex  beat  was  an  inch  external  to  the  nipple  line  (dilatation),  and 
the  sounds  were  the  same.  There  was  no  enlargement  of  the 
spleen,  liver,  or  lymphatic  glands.  When  he  remained  in  bed  he 
was  tolerably  well,  but  when  he  got  up  and  walked  about  he  was 
ill  from  the  fatigue  and  excitement.  He  weighed  3  stone  3  pounds 
(45  pounds). 

Two  ounces  of  cod-liver  oil  were  ordered  to  be  rubbed  into  his 


ANEMIA.  699 

body  dailj^  and  reduced  iron  and  pejosin  to  be  taken  in  a  powder, 
tbree  times  a  day.* 

A  pint  of  supercarbonated  Scbwalbach  water  was  ordered  daily. 

May  14th. — He  improved  for  a  few  days,  and  then  became  worse 
again — he  had  been  occasionally  sick,  but  the  temperature  was 
normaL  He  had  lost  four  pounds  in  weight  since  last  report. 
There  was  dulness  below  the  left  clavicle,  and  some  harsh  breath- 
ing. The  dulness  w^as  more  perceptible  over  the  left  suprascapu- 
lar ridge;  below  this  and  between  the  inner  border  of  the  left 
scapular  and  spine  the  respiration  was  sniffling  and  tubular.  The 
appetite  was  poor,  the  pulse  quick  and  agitated,  the  face  more 
angular,  and  there  was  cough. 

The  asthenia  was  so  great,  and  the  child  so  exhausted,  that  an 
attack  of  diarrhoea  or  inability  to  take  food  might  have  induced 
dangerous  syncope,  and  if  he  escaped  this,  then  the  morbid  action 
might  have  originated  tubercular  disease.  But  fatal  cases  of 
simple  aneemia  do  occur  in  which  no  disease  can  be  found  after 
death.  The  bloodless  condition  extends  over  a  period  of  weeks  or 
months,  and  no  remedy  has  the  least  effect  in  improving  its  quality. 
The  internal  organs  are  pallid,  and  in  some  instances  there  may  be 
slight  effusion  into  the  serous  cavities  or  subcutaneous  tissues  of 
the  body.  "  We  have  now  seen  several  of  these  cases ;  the  blood 
resembled  pink  water,  and  formed  no  coagula  in  the  vessels  or 
heart.  The  latter  organ  exhibits,  in  a  marked  degree,  that  form 
of  fatty  degeneration  where  the  internal  surface,  especially  the 
left  ventricle,  presents  the  peculiar  mottling  from  change  in  the 
muscular  fibre. "f 

October  22d — He  went  to  Kingston-on-Thames  in  June,  1878, 
and  stayed  there  two  months.  He  had  resumed  school,  and  al- 
though very  pale,  there  was  some  return  of  color  in  the  lips,  and 
he  had  gained  in  flesh.  The  harsh  breathing  below  the  left 
clavicle  had  departed,  but  the  cardiac  and  cervical  murmurs  were 
the  same. 

The  treatment  of  chronic  omoemia  will  depend  upon  the  cause  and 
the  condition  of  the  patient.     If  the  strength  is  much  reduced, 

*  Formula  94 : 

R.  Ferri  redact!, 
Sacchar.  pur. 
Pepsinse  porci,  aa •     gr-  ij- — ^^■ 

f  Pathological  Anatomy,  by  Wilks  and  Moxon,  1875,  p.  636. 


700  DISEASES    OF    CHILDREN. 

and  the  heart  weakened,  we  should  keep  the  patient  as  much  as 
possible  in  the  prone  position  till  he  has  regained  a  little  strength, 
and  the  heart  is  steadier.  If  this  precaution  be  not  observed,  there 
is  the  possibility  of  frequent  faintings,  and  even  fatal  syncope,  if 
the  disease  has  been  of  long  standing,  and  the  nutrition  of  the 
heart  has  suifered. 

Foremost  in  the  list  of  remedies  for  the  treatment  of  ancemia 
are  preparations  of  iron.*  They  have  an  astringent,  a  stimu- 
lating, and  a  tonic  action ;  some  are  irritating  to  the  mucous 
membrane  of  the  stomach,  causing  pain  and  uneasiness  when  it  is 
weak,  and  others  are  easily  soluble,  producing  no  unpleasant  effects. 
It  is,  therefore,  very  important  to  make  a  careful  selection  when 
any  salt  of  iron  appears  to  be  indicated.  In  the  anaemia  of  which 
we  have  been  speaking,  the  ammonio-citrate  of  iron  is  one  of  the 
best  remedies.  It  scarcely  ever  disagrees,  and  may  be  continued 
for  weeks  together  with  the  best  results.  It  produces  neither  pain, 
constipation,  nor  sickness,  and  in  my  experience,  I  look  upon  it  as 
the  best  blood  restorer  we  possess  in  simple  anssmia.  It  may  be 
given  in  syrup  and  water,  with  or  without  a  grain  of  carbonate  of 
ammonia  (Form.  95). t  This  is  a  good  combination  where,  in  ad- 
dition to  the  anfemic  state,  the  child  is  depressed  and  languid. 
When  there  is  great  debility,  characterized  by  a  hsemic  murmur 
over  the  base  of  the  heart,  and  the  tongue  is  flabby  and  indented 
by  the  teeth,  the  tincture  of  the  perchloride  of  iron  with  glycerin 
and  water  is  an  excellent  tonic  (Form.  96).:j:     Half  a  grain,  or  a 

*  "  Iron  possesses  the  power  of  augmenting  the  number  of  the  blood  corpuscles  as 
well  as  increasing  the  haemoglobin.  This  is  perfectly  effected,  according  to  Dr.  W.  R. 
Gowers,  by  the  chloroxide  of  iron  (dialyzed  iron).  In  the  course  of  five  weeks  under 
the  use  of  this  remedy  the  corpuscles  increased  greatly  in  number,  followed  by  re- 
covery of  the  patient,  who  suffered  from  pallor,  shortness  of  breath,  and  giddiness  on 
exertion." — The  Numeration  of  Blood  Corpuscles,  The  Practitioner,  July,  1878,  j).  10. 

f  Formula  95: 

R.  Ferri  et  amm.  citr gr.  xvj 

Amm.  carb., gr.  viij 

Syrup, 3iij 

Aquam  ad §iv. — M. 

A  dessertsjjoonful  three  times  a  day. 

X  Formula  96 : 

R.  Tinct.  ferri  pcrchlor, njjxl 

Glycerini,  .........     ^iij 

Aquam  cinnamomi  ad      ......         .     ^iv. — M. 

A  dessertspoonful  three  times  a  day. 


ANJiJMTA.  701 

grain  of  quinine  may  sometimes  be  advantageously  added  to  each 
dose  of  the  mixture. 

There  are  other  forms  of  iron  which  children  take  readily 
enough,  and  as  it  is  advisable  to  change  the  preparation  from  time 
to  time  where  the  blood  remains  impoverished  long  together,  we 
possess  valuable  remedies  in  the  syrup  of  phosphate  of  iron,  the 
syrup  of  hypophosphite  of  iron,  Parrish's  chemical  food,  steel 
wine,  and  the  syrup  of  the  iodide  of  iron.  Iron  lozenges  [Troch. 
Ferri  Bedad.)  will  be  found  useful  in  some  cases  after  the  chief 
meals  of  the  day.  They  are  tasteless,  and  the  mode  of  adminis- 
tration is  most  convenient.  One  grain  of  reduced  iron  is  con- 
sidered by  Messrs.  Squire  to  be  equivalent  to  five  grains  of  citrate 
of  iron.* 

In  those  cases  of  anfemia  where  children  have  not  lost  flesh,  but 
are  puffed  and  flabby,  the  muscles  soft,  and  the  bowels  torpid,  a 
mixture  containing  a  few  grains  of  sulphate  of  magnesia  with 
sulphate  of  iron,  or  the  solution  of  the  perchloride  (Form.  97),t 
will  sometimes  rouse  the  digestive  functions,  regulate  the  bowels, 
increase  the  appetite,  and  prove  highly  beneKcial. 

Belladonna  may  be  given  with  the  tincture  of  the  perchloride 
of  iron  when  the  action  of  the  heart  is  quick  and  fidgety.  It 
is  of  benefit  in  two  ways,  it  reduces  the  frequency  of  the  heart's 
beats,  by  which  it  has  time  to  gain  tone,  and  it  probably  has 
the  effect  of  counteracting  the  constipating  effects  of  the  iron 
(Form.  98).:j: 

The  supercarbonated  Schwalbach  water  is  an  excellent  chaly- 

*  Companion  to  the  British  Pharraacopoeia,  lltli  edit.,  1877,  p.  143. 
f  Formula  97  : 

R.  Magnes.  sulph., gr.  xvj 

Acid,  sulph.  dil., tr^iij 

Ferri  sulph., .         .     gr.  iv 

Vel  tinct.  ferri  perch., tt^xI 

Syr.  zingib., ^ij 

Aquam  carui  ad         ........     ^iv. — M. 

A  dessertspoonful  three  times  a  day.     For  children  from  five  to  ten  years  of  age. 
X  Formula  98 : 

R.  Tinct.  belladonna 

Tinct.  ferri  perch,  aa.,  .         .         .         .         .         .         .     ^xl 

Spt.  chloroform, ^xvj 

Glycerini, ^iij 

Aquam  ad 3iv. — M. 

A  dessertspoonful  three  times  a  day.     For  children  from  five  or  ten  years  of  age. 


702.  DISEASES   OF   CHILDEEX. 

beate  tonic,  improving  the  quality  of  tlie  blood  in  these  states  of 
an?eniia,  and  exercising  a  beneficial  influence  over  the  digestive 
and  assimilative  functions.  For  hospital  purposes,  however,  it  is 
too  expensive. 

Pernicious  or  idiopathic  ancemia  is  a  disorder  first  described  by 
Dr.  Addison  in  1843.  I  may  refer  to  it  in  this  place,  partly  be- 
cause it  is  a  form  of  an?emia  which  relatively  speaking  is  acute, 
partly  on  account  of  cases  being  recorded  among  children.  More- 
over, it  has  recently  occupied  much  attention.  Dr.  Addison  termed 
it  "  idiopathic  ancemia"  Biermer  called  it  "  progressive  pernicious 
ancemia.''  Practically  it  may  be  described  as  a  disease  where 
anaemia  sets  in  without  any  appreciable  cause,  and  is  unattended 
by  glandular  or  visceral  disease,  or  even  by  loss  of  flesh.  It  pro- 
gresses rapidly,  and  destroys  life  in  from  six  to  twelve  months, 
and  is  most  rapidly  fatal  in  young  subjects.  It  is,  however,  usually 
observed  in  patients  past  the  middle  period  of  life.  Dr.  Stephen 
Mackenzie,  in  an  interesting  lecture  on  the  subject,  describes  a 
case  of  idiopathic  aufemia  in  a  schoolboy,  aged  JO  years,  who  died 
five  months  after  the  onset  of  the  symptoms.  At  first  he  became 
white,  "  like  wax,"  and  the  pallor  rapidly  increased,  with  great 
perspiration,,  giddiness,  and  chilliness.  Admitted  into  hospital 
two  months  and  a  half  before  death,  he  was  found  to  have  optic 
neuritis,  and  a  sj'Stolic  murmur  loudest  at  the  apex.  His  blood 
contained  very  pale  red  corpuscles,  some  of  which  were  not  more 
than  a  quarter  of  the  usual  size,  and  of  these  some  were  tailed. 
There  was  no  increase  of  white  blood  cells.  He  died,  after  several 
attacks  of  uncontrollable  vomiting,  epistaxis,  and  bleeding  from 
the  gums.* 

A  case  of  idiopathic  ansemia  is  recorded  by  Sir  William  Gull, 
in  which  he  states  his  belief  that  "  the  line  of  morbid  action  seems 
to  be  through  the  nervous  system  interfering  with  the  functions  of 
digestion,  or,  more  generally  speaking,  of  h8emapoiesis."t  I  think 
this  view  is  in  a  great  measure  the  correct  one,  looking  at  the  high 
temperature  which  is  so  often  noticed  in  children,  the  subjects  of 
confirmed  aniemia,  after  food,  fatigue,  or  excitement,  changes  in 
the  weather,  and  so  forth. 

Simple  enlargement  of  the  cervical  lymphatic  glands  cdong  with 
ancemia  occurs  so  often  in  delicate  and  strumous  children,  that 


*  The  Lancet,  vol.  ii,  1878,  pp.  797-833. 
f  Trans.  Path.  Soc,  vol.  xxix,  p.  383. 


ENLARGED  CERVICAL  GLANDS  703 

some  special  notice  is  needed  of  its  nature.  The  complaint  is 
exceedingly  common  in  hospital  practice.  Cold,  impaired  health, 
and  the  irritation  arising  from  the  exanthemata,  and  particularly 
scarlet  fever  and  diphtheria,  excite  the  lymphatic  vessels,  and  cause 
the  glands  to  inflame  and  swell.  The  hj^perplasia  is  inflammatory, 
the  cell  elements  and  connective  tissue  being  increased.  The  glands 
so  affected  may  remain  for  an  indefinite  time  enlarged  and  tender; 
then  they  gradually  shrink,  and  resolution  takes  place,  if  the 
a'eneral  health  and  constitution  are  good.  Thev  sometimes  give 
rise  to  neither  pain  nor  inconvenience  of  any  sort.  They  occur  to 
children  in  fair  health,  who  get  an  occasional  sore  throat,  the 
swelling  suLsiding  in  the  course  of  a  few  days.  If  the  child  is 
delicate,  and  comes  of  a  strumous  famil}-,  we  speak  of  "  scrofulous  " 
enlargement,  so  common  in  the  out-department  of  our  hospitals. 
A  gland  swells,  and  remains  enlarged  for  some  time  ;  then  another 
gland,  or,  indeed,  several  glands,  become  implicated,  the  morbid 
process  spreading  from  one  to  the  other,  and  suppuration  occurs 
in  them  one  by  one,  till  they  either  ulcerate  and  discharge  a  caseous 
kind  of  pus,  or  it  may  be  considered  advisable  to  open  them.  In 
either  case  a  puckered  and  ugly  scar  remains  for  life.  When  the 
suppurating  glands  are  not  opened  by  the  surgeon,  it  sometimes 
happens  that  the  matter  within  becomes  absorbed,  leaving  a  hard 
concretion  in  the  neck.  These  enlarged  glands  ma}'  be  seen  some- 
times in  children  who  are  tuberculous,  showing  no  tendency  to 
suppurate.  It  is  in  such  cases  as  these,  that  the  cervical  glands 
remain  large,  uneven,  and  irregular  in  shape,  without  any  tender- 
ness or  discoloration  of  the  skin.  Thej^  are  freely  movable  and 
non-adherent.  The  glands  usually  affected,  are  the  cervical,  in- 
guinal, axillary,  and  mesenteric.  In  the  neck,  they  are  often  found 
inflamed  and  tender  from  sore  throat,  dentition,  and  catarrh. 

The  treatment  varies  with  the  condition  of  the  gland.  When 
the  enlarged  glands  have  passed  into  a  chronic  and  indolent  state, 
they  are  very  obstinate  in  yielding  to  any  method  of  treatment. 
If  the  source  of  irritation  can  be  ascertained,  it  should  be,  if  pos- 
sible, cured  or  removed  ;  as  eczema  of  the  scalp,  decayed  teeth,  etc. 
Then  we  may  proceed  to  deal  with  the  enlarged  glands.  The 
application  of  a  weak  solution  of  tincture  of  iodine  night  and 
morning,  or  slight  friction  with  iodine  ointment,  are  common  and 
useful  applications.  I  greatly  prefer  the  former.  When  suppura- 
tion threatens,  a  poultice  is  necessary,  and  as  soon  as  fluctuation 


704  DISEASES   OF   CHILDEEN. 

is  detected,  a  small  opening  should  be  made  horizontally  with  a 
lancet,  which  will  often  accelerate  the  cure,  and  cause  the  abscess 
to  contract.  But  if  matter  threatens  to  burrow,  the  abscess  must 
be  laid  open  freely.  The  constitutional  treatment  consists  in  pre- 
scribing good  food,  syrup  of  iodide  of  iron,  phosphate  of  iron,  cod- 
liver  oil.  Above  all,  children  suffering  from  these  chronic  glan- 
dular affections  should  have  the  benefit  of  sea-air  if  it  can  be  ob- 
tained. 

Lymphadenoma  is  allied  to  leukaemia.  It  may  be  described  as 
a  morbid  affection  of  a  scrofulous  character,  attended  with  great 
enlargement  of  the  lymphatic  glands,  and  a  peculiar  deposit  in 
the  Malpighian  bodies  of  the  spleen.  There  is  either  a  new  growth 
or  hj'pertrophy  of  the  normal  lymphatic  tissue.  In  a  histological 
point  of  view  it  resembles  leuktemia,  but  it  differs  from  it  in  that 
there  is  no  excess  of  white  corpuscles  in  the  blood,  and  from  tuber- 
cle in  having  only  a  slight  disposition  to  undergo  the  like  degen- 
erative changes.  But  it  may  ulcerate  and  become  the  seat  of 
haemorrhage,  or  fatty  change,  or  caseation.  Suppuration,  which, 
as  we  have  already  seen,  is  so  common  in  the  idiopathic  or  simple 
inflammatory  enlargement  of  the  cervical  glands  in  young  strumous 
subjects,  with  which  affection  lymphadenoma  is  anatomically 
allied,  does  not  occur. 

The  lymphatic  glands  increase  rapidly  in  size,  forming  tumors 
of  brainlike  consistence,  elastic,  of  a  whitish-yellow  color,  and 
adherent  in  masses.  The  disease  involves  the  lungs,  liver,  kid- 
nej'S,  stomach,  muscles,  bones,  and  subcutaneous  tissues,  in  which 
a  new  growth  of  lymphatic  tissue  is  either  infiltrated  through 
them,  or  deposited  as  a  mass  or  tumor  in  the  substance  of  these 
different  organs.  j 

Another  characteristic  feature  of  the  disease  is  the  effect  it 
sometimes  produces  on  the  blood,  the  red  corpuscles  being  dimin- 
ished and  the  white  increased,  so  that  in  such  a  case  lymphade- 
noma may  be  said  to  produce  leucocythemia. 

The  disease  commences  gradually  in  the  lymphatic  glands  about 
the  neck,  and  after  a  time  it  spreads  and  involves  other  organs  in 
a  similar  morbid  process.  It  is  associated  with  failing  health 
and  cachexia,  and  it  pursues  the  same  fatal  course  as  malignant 
growths  generally,  with  which  it  has  a  close  and  intimate  con- 
nection. 

"  A  case  of  rapidly  fatal  lymphadenoma  "  is  described  by  Dr. 


LYMPHADENOMA.  7U5 

Garlick.*  A  male  child,  aged  seven,  was  admitted  into  the  Hos- 
pital for  Sick  Children  January  5th,  1878.  There  was  a  family 
history  of  phthisis  and  struma.  A  large  mass  of  glands  appeared 
on  the  left  side  of  the  neck  two  months  and  a  half  before  death, 
with  rapid  deterioration  of  health  ;  at  the  last  there  was  asthenia, 
dysphagia,  occasional  dyspnoea,  and  diarrhoea,  with  high  temper- 
ature. On  a  post-mortem  examination,  twenty-live  enlarged  and 
vascular  cervical  glands  were  seen  on  the  left  side  of  the  neck, 
the  tracheal  and  bronchial  glands  were  enlarged,  and  there  was  a 
large  vascular  lymphatic  "gland  in  the  hilus  of  the  kidney ;  in  the 
spleen  enlargement  of  the  Malpighian  bodies  from  new  cell  growth 
in  the  sheaths  of  the  vessels ;  in  the  liver  lymphoid  growths,  the 
largest  the  size  of  a  hemp-seed,  the  adjacent  liver  cells  in  a  state 
of  fatty  degeneration. 

Another  case  of  interest  is  described  by  Mr.  Macnamara.f  "  A 
fair-haired,  blue-eyed,  intelligent  lad  "  had  been  admitted  into  the 
Stepney  Sick  Asylum,  The  general  health  was  good  till  June, 
1878,  when  rapid  enlargement  of  the  right  cervical  glands  com- 
menced. There  was  a  history  of  hereditary  tuberculosis.  On 
admission  into  hospital  the  glands  on  the  right  side  of  the  neck 
felt  like  a  firm  sarcomatous  growth,  with  here  and  there  soft 
patches.  The  glands  were  also  enlarged  on  the  left  side.  There 
was  neither  albuminuria,  dropsy,  nor  leucocytosis.  Pleurisy  came 
on  soon  after  admission,  and  he  sank  from  impeded  respiration 
and  effusion  into  the  pleura,  five  months  after  the  commencement 
of  the  symptoms.  After  death  all  the  lymphatic  glands  in  the 
body  were  found  to  be  hypertrophied  ;  yellowish-gray  nodules 
were  found  on  the  surface  of  the  liver,  spleen,  and  base  of  both 
lungs.  Mr.  Macnamara  detected  remarkable  changes  in  the  me- 
dulla and  periosteum  of  the  bones. 

Mr.  Alban  Doran  gives  me  the  following  particulars  of  a  case 
which  he  closely  observed  when  house-surgeon  to  Mr.  Holden,  at 

St.  Bartholomew's  Hospital,  the  subject  being  a  boy,  A.  P , 

aged  11  years.  At  Christmas,  1872,  a  tumor  began  to  appear  on 
the  right  side  of  the  neck,  below  the  lower  jaw.  It  rapidly  grew 
larger.  When  admitted  into  the  hospital  on  June  10, 1873,  there 
was  a  great  mass  of  enlarged  glands  on  the  right  side,  from  the 
chin  to  the  sternum.     The  whole  growth  felt  lobular,  firm  under 

*  Trans.  Path.  Soc,  vol.  xxix,  p.  355. 
f  Ibid.,  vol.  xix,  p.  360. 
45 


706  DISEASES   OF   CHILDREN. 

the  jaw,  soft  in  tlie  middle,  and  at  the  lowest  part  was  a  fluctn- 
atiiig  projection  the  size  of  a  marble.  The  skin  over  the  tumor 
was  red,  and  a  week  after  admission  it  became  adherent  to  the 
glands,  though  when  first  examined  it  was  quite  free.  Consider- 
able enlargement  of  the  npper  cervical  glands  on  the  left  side 
existed.  One  gland  in  the  right  axilla  was  enlarged.  There  was 
impaired  resonance  and  feeble  respiration  over  the  front  of  left 
luno['.  No  enlaro-enient  of  the  liver  could  be  detected,  nor  was 
there  any  preponderance  of  white  cells  in  the  blood.  On  applying 
a  trocar  to  the  lowest  part  of  the  tumor  on  the  right  side  of  the 
neck,  chocolate-colored  fluid  escaped,  consisting  of  red  corpuscles 
with  numerous  white  blood-cells.  The  tnraors  rapidly  increased  ; 
for  two  nights  (June  28th  and  29th,  1873)  he  suffered  from 
dyspnoea.  Late  in  July  the  tumor  on  the  right  side  ulcerated, 
and  hseraorrhage  followed,  cheeked  by  cold.  This  tumor  at  length 
sloughed  away,  the  patient  became  extremely  emaciated,  and  died 
on  September  10th. 

Post-mortem  Examination. — The  tumor  on  the  right  side  was 
reduced  to  a  flaccid  bag  of  sloughs  extending  from  the  zygoma  to 
the  clavicle.  The  tumor  on  the  left  side  was  smaller;  the  upper 
portion  resembled  on  section  an  ordinary  enlarged  gland ;  the 
remainder  was  softer,  very  vascular,  and  deep  red.  The  bronchial 
glands  and  one  mesenteric  gland  presented  the  same  appearance, 
being  red  and  almost  pulpy.  The  spleen  was  very  pulpy,  the  size 
of  a  small  orange,  and  deeply  lobulated.  The  glands  in  the  trans- 
verse fissure  of  the  liver  were  pale  and  slightly  enlarged ;  the 
heart,  lungs,  liver,  and  kidneys  were  normal,  but  the  left  kidney 
was  indurated  by  the  enlarged  spleen,  and  slightly  congested. 
There  was  intussusception  of  about  two  inches  of  ileum.  * 

The  treatment  consisted  in  the  administration  of  cod-liver  oil, 
and  ferruginous  tonics.  Dr.  Gowers  relates  two  cases  where  the 
blood-corpuscles  in  this  disease  increased  20  per  cent,  during  the 
administration  of  phosphorus.* 

Leucocythcemia  [leucocytosis — leukcemia  of  Virchow)\  is  occasionally 

*  The  Numeration  of  Blood-Corpu.sdes,  The  Practitioner,  1878. 

f  As  poinled  out  by  Dr.  Hughes  Bennett  and  Dr.  Parkes,  loukremia  ("white 
blood")  is  not  a  good  term,  because  if  the  blood  be  drawn  from  the  arm  it  is  red. 
Leucocythsemia ;  Xevidic,  white,  icvrog^  cell;  and  al/xa^  blood — white-cell  blood,  ex- 
presses the  true  pathological  fact,  viz.,  that  the  blood  abounds  in  colorless  corpuscles. 
Principles  and  Practice  of  Medicine,  by  J.  Hughes  Bennett,  M.D.,  1857,  p.  858. 

According  to  Dr.  Michael  Foster  the  white  cells  in  lukaemia  are  in  the  proportion  of 
one  to  ten  red. 


LEUCOCYTH^MIA.  707 

met  Tvith  in  cliilclren.  It  is  a  peculiar  disease  of  modern  discovery, 
consisting  of  an  increased  number  of  white  corpuscles  in  the 
blood,  and  the  formation  of  a  new  lymphatic  tissue  in  the  spleen, 
lymphatic  glands,  liver,  kidneys,  and  various  other  organs  of  the 
body.* 

"  It  is  probable  that  the  power  of  the  white  blood-corpuscles  and 
lymph-corpuscles  to  form  red  corpuscles  is  diminished.  Possibly 
also  the  white  corpuscles  may  increase  by  multiplication  in  the 
blood. "t  The  disease  is  unconnected  with  inflammation,  but  some- 
times associated  with  tubercalosis,  Bright's  disease,  and  cancer.  It 
has  been  estimated  by  some  writers  that  the  proportion  of  red 
and  white  corpuscles  is  about  the  same,  the  red  being  arranged  in 
rouleaux,  and  the  white  filling  up  the  spaces  between  them. 
Many  of  the  white  corpuscles  are  larger,  more  granular,  and  con- 
tain a  single,  a  double,  or  a  treble  nucleus. 

The  constitutional  symptoms  of  leucocj'thpemia  vary  in  severity  ; 
they  are,  extreme  pallor  and  cachexia,  a  blanched  conjunctiva, 
languor  on  exertion,  frequent  vomiting,  thirst,  diarrhoea,  or  con- 
stipation. There  is  generally  enlargement  of  the  spleen,  liver,  and 
lymphatic  glands.  There  may  be  oedema  of  the  lower  limbs,  or 
ascites,  and  owing  to  the  changed  state  of  the  blood,  epistaxis, 
and  bleeding  from  the  gums  sometimes  happen.  The  urine  is 
often  loaded  with  lithates.  When  the  liver  is  enlarged  at  an  early 
stage  there  may  be  jaundice.  Dr.  Greenfield  describes  a  case  of 
leucocythsemia  in  a  female  child,  aged  four  and  a  half,  wMch. 
proved  fatal.  The  leading  symptoms  were  extreme  pallor,  and 
large  bruised-like  spots  appeared  on  the  limbs.  After  death, 
extensive  infiltration  of  leucocytes  were  found  in  the  liver,  kidneys, 
and'  heart.  In  this  case,  however,  there  was  a  distict  history  of 
syphilis  in  the  father  and  mother,  with  the  ordinary  hereditary 
symptoms  in  the  patient  herself:]: 


*  Next  to  the  spleen,  the  liver  is  most  commonly  found  diseased  in  leucocythsemia. 
Ibid.,  p.  873. 

f  Pathological  and  Morbid  Anatomj',  by  T.  H.  Green,  M.D.,  1871,  p.  140. 
J  Trans.  Path.  Soe.,  vol.  xxix,  p.  298. 


V        708  DISEASES    OF    CHILDEEX. 

CHAPTER   LII. 

DISEASES    OF    THE    EAR. 

Frequent  in  childhood — Peculiarities  of  the  ear  in  childhood — -Catarrhal  deafness — Bs  rela- 
tion to  coryza,  tonsillitis,  etc. — jEvil  effects  of  obstruction  of  the  Eustachian  tube — Treat- 
tnerd.  Otorrhcea  :  Its  causes — Cases  Ulastratiny  extreme  results  of  suppurative 
inflammation  of  tympanum,  etc. — Diagnosis  simple.  Aural  Polypi:  Frequency  of 
peiforation  of  membrana  tympani — Examination  of  the  ear — Detection  of  perforation — 
General  and  local  treatment — Injections — Management  of  perforation — Artificial  mem- 
brdna  tympani.   Eczema  of  Auricle.   Abscess  of  Mlatus.    Causes  and  treatment. 

Tvro  diseases  of  the  organ  of  hearing  are  so  far  more  frequent 
in  childhood  than,  any  other  disorder  of  the  ear  that  they  should 
be  described  before  all  others.  These  diseases  are  catarrhal  deaf- 
ness and  otorrhcea. 

The  middle  and  internal  ear  is  very  similar  in  childhood  and  in 
adult  life,  owing  to  the  early  development  of  its  structures..  The 
three  little  auditory  ossicles  are  almost  full  grown  at  birth,  so 
that  the  stapes  of  an  infant  is  very  little  smaller  than  that  of  a 
giant  trooper  in  a  Guard  regiment. 

On  the  other  hand,  the  outer  bony  structures  of  the  ear  are 
very  different  at  birth  to  what  they  are  in  youth  and  in  the  adult 
stage.  There  is  absolutely  no  bony  external  meatus,  but  a  mere 
ring  of  bone  in  the  new-born  infant,  destined  to  enlarge  externally 
80  as  to  form  that  osseous  canaL  Hence,  in  very  young  children 
the  membrana  tympani  is  much  nearer  the  surface  than  in  adults. 
The  plane  of  that  membrane,  too,  is  nearly  horizontal,  so  that  it 
lies  almost  level  with  the  base  of  the  skull,  as  may  be  seen  on 
examining  the  under  surface  of  a  fetal  skull. 

The  membrana  tympani  cuts  off  the  external  meatus  from  the 
cavity  of  the  tympanum.  This  membrane  is  vascular,  and  readily 
conveys  inflammation  from  one  side  to  the  other.  Hence  the 
frequency  of  inflammation  of  the  tympanum  when  its  external 
membrane  has  inflamed  from  cold,  damp,  or  some  injury  on  its 
outer  aspect.  The  tympanic  cavity  communicates  with  the  pharynx 
by  the  Eustachian  tube,  and  is  lined  by  mucous  membrane.  That 
canal  is  opened  during  every  act  of  swallowing.  The  sound  of 
air  rushing  into  the  tympanic  cavities  can  be  recognized  as  two 
simultaneous  clicks,  during  the  act  of  swallowing  a  little  water, 
and  this  becomes  more  manifest  when  the  nose  is  closed.  The 
presence  of  air  on  the  inner  as  well  as  on  the  outer  side  of  the 


DISEASES    OF    THE    EAR.  709 

membrana  tympani  is  absolutely  necessary  for  the  exact  trans- 
mission of  vibrations.  It  is  doubtful  whether  the  air  in  the 
tympanum  be  of  the  same  density  as  the  external  atmosphere.* 

Frequent  attacks  of  acute  coryza,  or  of  sore  throat,  so  common 
in  childhood,  cause  thickening  of  the  mucous  membrane  of  the 
Eustachian  tube,  which  thus  becomes  obstructed.  Simultaneous 
enlargement  of  the  tonsils  generally  exists,  but  this  complication 
does  not  much  increase  the  defect  of  hearing.  The  child  com- 
plains of  a  heavy  feeling  in.  one  or  both  ears,  and  becomes 
decidedly  deaf.  Incipient  deafness  is  often  mistaken  for  dulness 
of  intellect  or  wilful  inattention  to  the  commands  of  a  teacher, 
and  so  the  poor  child  is  often  unfairly  ridiculed  or  punished. 
From  the  tubes  the  inflammation  extends  to  the  tympanic  cavity. 
Pain  in  the  ear  theu  becomes  frequent,  and  through  exposure  to 
damp,  the  mild  inflammatory  stage  assumes  an  acute  form,  with 
increase  of  suffering.  The  blocking  of  the  Eustachian  tube  causes 
great  external  concavity  of  the  membrana  tympani,  owing  to 
atmospheric  pressure  being  greater  without  than  within  the 
tympanum.     This  may  permanently  damage  the  membrane. 

All  these  common  forms  of  "  catarrhal  deafness  " — whether  due 
to  chronic  inflammation  of  the  Eustachian  tubes,  or  to  chronic  or 
subacute  inflammatory  processes  going  on  within  the  tympanum, 
may  come  under  the  notice  of  the  physician.  Some  of  the  most 
necessary  curative  measures — particularly  for  inflation  of  the 
Eustachian  tubes — must  be  left  to  the  surgeon.  But  the  same 
general  and  local  measures  that  are  of  benefit  in  tonsillitis  and 
coryza  will  be  required  when  the  mucous  membrane  of  the  audi- 
torj^  apparatus  is  involved.  Without  them,  surgical  interference 
will,  at  most,  insure  only  temporary  improvement.  Hence  tonics, 
cod-liver  oil,  weak  astringent  applications  (as  in  tonsillitis),  and 
fresh  air  are  imperative. 

The  most  troublesome  of  all  diseases  of  the  ear  in  childhood  is 
purulent  inflammation  of  the  tympanic  mucous  membrane,  with 
perforation  of  the  membrana  tympani  and  escape  of  unhealthy 
pus  by  the  external  meatus.  Circumscribed  suppuration  within 
the  tympanum  is  very  rare.  An  interesting  case  of  acute  otitis, 
terminating  in  abscess  of  the  tympanum,  is  related  by  Dr.  Moor- 
head,  in  a  boy,  15  years  of  age.  It  commenced  with  acute  pain  in 
the  left  ear,  th^e  temperature  rose  to  102^,  and  the  pulse  to  120. 

*  See  Keene,  On  Middle-Ear  Deafness,  The  Lancet,  vol.  ii,  1878,  p.  690. 


710  ^  DISEASES    OF    CHILDRE^N". 

Hearing  was  impaired,  and  the  membrana  tympani  became  opaque. 
Under  the  use  of  leeches  and  antiphlogistic  remedies,  the  pulse 
and  temperature  fell  to  normal.  The  breath  was  very  fetid,  and 
it  soon  became  evident  that  pus  which  had  been  pent  up  in  the 
tympanic. cavity  had  found  its  way  through  the  Eustachian  tube 
into  the  throat.  Three  weeks  later,  the  deafness  being  still  ex- 
treme, the  patient  suddenly  heard  a  loud  noise  in  the  affected  ear, 
followed  by  an  escape  of  fetid  pus  through  the  Eustachian  tube, 
and  the  restoration  of  hearing.* 

Otorrhoea  must  always  be  regarded  with  suspicion  ;  it  may  lead 
to,  meningitis,  facial  paralysis,  or  other  grave  affection. f 

Otorrhoea  often  commences  as  a  low  form  of  catarrhal  deafness  / 
in  sickly  strumous  children.  But  it  also  very  frequently  appears 
as  a  local  result  of  great  general  impairment  of  health  after  the 
exanthemata,  particularly  scarlatina,  and  other  acute  diseases. 
Field  remarks:  "The  mucous  membrane  is  liable  to  inflamma- 
tions, usually  of  a  catarrhal  kind,  which  are  analogous  with  the 
changes  seen  in  other  mucous  membranes.  The  most  severe  forms 
are  those  which  are  extensions  of  the  inflammations  occurring  in 
the  mucous  membrane  of  the  fauces  and  pharynx  in  diphtheria 
and  scarlet  fever ;  these  pass  along  the  Eustachian  tube,  and  affect- 
ing the  tympanum  with  the  same  severity  they  do  the  throat, 
often  work  terrible  havoc  there;  for  not  only  will  they  fill  it  with 
pus  and  produce  perforation,  by  inflammation  and  overdistension 
of  the  drum-membrane,  but  frequently  the  deeper  structures  are 
also  involved,  so  that  the  periosteum  becomes  injured,  and  caries 
or  necrosis  of  the  bony  walls  ensue,  producing  in  many  cases  an 
utter  destruction  of  the  organ,  if  not  of  the  individual.  The  perils 
of  meningitis,  phlebitis,  abscess  of  the  brain,  pysemia,  and  the  like, 
are  all  threatening  when  this  most  severe  form  of  disease  in  the 
tympanum  occurs.  We  may  consider  it  fortunate  sometimes 
when  the  cavity  becomes  blocked  with  a  mass  of  chees}^  material 
which  may  become  quiescent ;  though  unfortunately  remaining  as 
a  hidden  danger,  which  at  any  time  may  develop  into  an  active 
centre  of  infection,  and  cause  a  general  tuberculosis.  This  form  of 
disease  is  most  frequently  seen  in  young  children,  and  it  often 
aflects  both  ears  at  once ;  when  this  happens  they  generally  grow 
up  as  deaf  mutes. 


*  British  MedicalJournal,  vol.  ii,  1878,  p.  313. 
t  See  Chap.  XLII,  p.  561,  On  MeningitLs. 
X  Diseases  of  the  Ear,  2d  edit.,  p.  221. 


DISEASES    OF    THE    EAR.  711 

A  child  of  four,  admitted  into  the  Samaritan  Hospital,  in  the 
autumn  of  1878,  with  acute  tuberculosis  of  both  lungs,  was  found 
to  have  a  discharo-e  from  the  meatus  on  both  sides,  a  few  davs 
after  admission.  Noma  followed,  attacking  the  integuments 
behind  the  ears ;  and  after  the  patient's  death  the  right  petrous 
bone  was  found  to  have  become  necrOsed,  both  tympanic  cavities 
to  be  full  of  pus,  and  the  ossicula  quite  loose.  !N'ot  a  trace  of  the 
membrana  tjmpani  could  be  found  on  either  side.  This  case 
illustrates,  iu  a  very  aggravated  form,  the  etiology  and  course  of 
otorrhoea.  In  ordinary  cases,  the  discharge  may  last  for  months 
or  years,  issuing  through  a  small  hole  in  the  membrana  tympani ; 
but  caries  or  necrosis  of  the  neighboring  bones  is  fortunately 
rare. 

The  constant  purulent  or  muco-purulent  discharge  from  the 
meatus  renders  the  diagnosis  of  otorrhoea  very  simple.  The  dis- 
charge often  smells  offensively  when  no  disease  of  the  bone  exists. 
A  copious  secretion  from  the  external  meatus  alone  is  so  unusual, 
that  a  free  escape  of  any  morbid  fluid  from  that  passage  implies, 
as  a  rule,  perforation  of  the  membrana  tympani.  This  complica- 
tion, or  rather,  this  constant  feature  in  chronic  otorrhoea,  is  not  in 
itself  serious,  as  the  tympanic  cavity  thereby  becomes  accessible 
to  irjections. 

A  purulent  discharge  from  the  meatus  often  gives  rise  to  poly- 
poid growths,  and  according  to  the  author  just  quoted,  "  Polypi 
frequently  occur  in  the  middle  ear,  and  are,  perhaps,  invariablj' 
the  results  of  inflammation.  Their  structure  and  history  vary 
with  the  severity  of  the  inflammation,  and  the  parts  from  which 
they  spring.  The  most  common  is  the  ordinary  mucous  polypus, 
of  a  similar  nature  to  those  seen  in  the  nose  and  -uterus.  These 
spring  from  the  mucous  surface,  and  are  formed  of  soft  cellular 
tissue  ;  they  contain  reduplications  of  the  epithelial  surface  form- 
ing glandlike  tubes  or  sacs.  The  surface  of  the  growth  is  covered 
with  ciliated  cylinder  epithelium,  which  changes  sometimes  at  its 
extremity  to  a  mixed  or  pavement  epithelium.  More  rare  are  the 
fibromata  developed  from  the  periosteal  layer."  Aural  polypi 
arise  almost  invariably  from  the  walls  of  the  tympanic  cavity  and 
may  easily  be  removed  by  "Wilde's  polypus  snare. 

The  existence  of  a  hole  in  the  membrana  tympani  in  cases  of 
copious  discharge  is  indisputable,  from  clinical  evidence  and  from 
the  anatomical  peculiarities  of  the  tympanum.     Matter  escapes 


712  DISEASES    OF    CHILDREN. 

fhrough  the  least-resisting  structures  in  its  neighborhood.  In  the 
tympanum  the  Eustachian  tube  and  the  membrane  are  the  least- 
resisting  media  for  the  discharge  of  secretions.  But  the  tube  is, 
in  these  cases,  almost  always  partially  obstructed,  and  the  mem- 
brane, on  the  other  hand,  is  softened  by  inflammatory  changes,  so 
that  it  first  bulges  externally,  then  yields  at  one  point.  This 
perforation  may  for  some  time  remain  very  minute,  as  though  a 
pin  had  been  pushed  through  the  membrane,  but  it  may  be  so 
extreme  that  nothing  remains  but  a  crescentic  ridge  or  elevation 
at  the  bottom  of  the  external  meatus  to  mark  the  site  of  the 
membrana  tympani. 

Hinton,  speaking  of  catarrhal  inflammation  of  the  meatus,  with 
" more  or  less  profuse  semi-purulent  discharge,"  asserts  that  "so 
far  as  I  have  observed,  this  condition  is  a  concomitant  of  a  similar 
aifection  of  the  tympanic  cavity.  Many  cases  also  of  apparent 
catarrh  of  the  meatus  are  really  cases  of  minute  perforation  of 
the  membrane."*  Von  Troltsch,  in  reference  to  what  he  terms 
chronic  suppurative  aural  catarrh,  remarks  very  positively :  "Per- 
foration, or  partial  destruction  of  the  membrana  tympani,  is  always 
present  in  these  cases. "f 

Enlargement  of  the  upper  cervical  glands  is  a  very  general 
symptom  of  otorrhcea.  More  or  less  deafness  always  exists,  but 
very  irregular  in  degree,  for  it  may  be  extreme  in  a  mild  attack, 
whilst  it  is  sometimes  but  slight  after  destruction  of  the  greater, 
part  of  the  membrana  tympani  and  loss  of  the  ossicles.  It  has 
long  been  a  truism  that,  if  the  stapes  fall  out,  inevitable  and  com- 
plete loss  of  hearing  must  follow.  Still,  we  must  remember  that 
in  all  things  the  most  experienced  men  are  the  most  sparing  in 
very  positive  assertions.  And  it  is  well  to  notice  that  in  this 
matter  Hinton  observes  :  "  Whether  total  deafness  necessarily  re- 
sults from  loss  of  the  stapes,  involving,  as  it  must  do,  the  discharge 
of  the  perilymph  from  the  internal  ear,  is  as  yet  undecided."! 

In  chronic  otorrhcea,  the  pain  is  slight,  as  a  rule,  but  occasion- 
ally it  becomes  severe,  if  the  discharge  be  very  copious,  and  unable 
to  escape  freely. 

Diagnosis. — The  muco-purulent  discharge  is  pathognomonic  of 
otorrhcea,  but  it  is  necessary  to  ascertain  the  amount  of  mischief 

*  Holmes's  System  of  Surgery,  2d  edit.,  vol.  iii,  p.  266. 

f  Surgical  Diseases  of  the  Ear,  trans,  by  J.  Plinton,  New  Syd.  Soc,  vol.  Ixii. 

X  Loc.  jam.  cit.,  p.  314. 


DISEASES    OF    THE    EAR,  713 

existing  in  any  given  case.  On  inspecting  the  meatus  the  dis- 
charge prevents  any  clear  view  of  the  deeper  parts.  So  the  ear 
should  first  be  syringed  out  with  lukewarm  water,  and  the  meatus 
cleared  by  means  of  a  piece  of  avooI  twisted  on  the  end  of  a  quill 
pen.  If  the  membrana  tympani  be  nearly  destroj'ed,  the  tym- 
panic cavity  may  then  be  clearly  seen  through  a  speculum,  the 
malleus  standing  out  boldly  in  relief  if  it  has  not  fallen  out,  and 
the  promontory  will  be  covered  with  bright-red  granulations.  But 
more  usually,  the  membrana  tympani  can  be  distinguished,  vas- 
cular in  appearance,  and  showing  a  small  perforation.  Yet  in 
many  instances  the  aperture  is  so  minute  that  it  cannot  be  seen  at 
first.  If,  whilst  the  medical  attendant  looks  through  the  speculum 
the  patient  be  directed  to  make  a  forcible  expiration,  with  his 
mouth  and  nose  firmly  closed,  some  of  the  discharge  will  be  seen 
issuing  through  the  aperture.  Under  similar  circumstances  the 
noise  of  air  rushing  through  the  perforation  may  be  heard  when 
the  Eustachian  tube  is  patent,  particularly  if  a  tube  be  placed  with 
one  end  in  the  patient's  ear  and  the  other  in  that  of  the  medical 
attendant,  during  the  inflation  of  the  Eustachian  tube.  In  cases 
of  minute  perforations,  invisible  on  first  inspection,  their  presence 
may  be  suspected  by  a  pulsating  movement  in  the  film  of  fluid 
covering  the  outer  side  of  the  membrana  tympani. 

Treatment. — Although  otorrhoea  often  disappears,  after  lasting 
for  years,  it  seldom  fails  to  produce  permanent  mischief  to  the 
sense  of  hearing,  and,  besides  its  oftensive  character,  the  results 
may  be  serious,  or  even  fatal.*  Fortunately,  few  local  diseases 
are  more  amenable  to  general  treatment.  Cod-liver  oil  and  steel 
wine,  judiciously  administered,  seldom  fail  to  check  the  discharge. 
But  this  benefit  is  effected  slowly  by  such  drugs,  so  that  it  is 
always  necessary  to  remove  daily  the  morbid  accumulation  that 
already  fills  the  meatus.  The  ear  should  be  syringed  out  with 
tepid  water  several  times  daily,  at  the  risk  of  causing  occasional 
faintness,  for  the  disuse  of  the  syringe  involves  worse  results. 
A  little  carbolic  acid  (1  in  40  or  50)  should  be  added  to  the  water 
when  there  is  fetor.  After  the  syringing,  a  few  drops  of  a  weak 
astringent  solution  should  be  poured  into  the  meatus.  Sulphate 
of  zinc  (gr.  j  to  v  in  .5J  of  water  with  5j  of  glycerin)  is  very  effi- 
cacious.    Acetate  of  lead  is  objectionable,  as  it  forms  a  precipitate 

*  See  an  instructive  chapter  On  tjie  Results  of  Suppurative  Inflammation,  Field's 
Diseases  of  the  Ear,  2d  edit.,  p.  136. 


714  DISEASES    OF    CHILDEEN. 

in  the  ear.  Alum  may  be  used  for  a  short  time,  but  its  effects 
must  be  carefully  watched,  as  it  irritates  the  meatus.  Strong 
caustics  hiive  been  used  with  great  success,  but  the  general  phy- 
sician and  surgeon  should  not  attempt  to  employ  them  unless  he 
has  had  unusual  clinical  experience  of  ear  diseases. 

When  the  discharge  is  checked  the  cure  of  the  perforation 
may  be  undertaken,  but  not  till  then.  The  edges  of  the  aperture 
should  be  touched,  through  a  speculum,  with  a  stick  of  nitrate  of 
silver.  If  the  membrana  tympani  be  quite  or  almost  completely 
destroyed,  an  artificial  membrane  should  be  worn.  The  more 
simple  contrivance  of  Yearsley — a  plug  of  moistened  wool — is 
often  very  efficacious.  Its  application  is  best  performed  in  the 
way  described  by  the  late  Mr.  Ilinton. 

For  the  cotton-wool  I  prefer  glycerin  to  water,  as  it  will  then 
retain  sufficient  moisture  not  to  need  changing  for  four  or  five 
days ;  and  in  most  cases  I  add  to  the  ounce  of  glycerin  from  five 
to  twent}^  grains  of  sulphate  of  zinc.  Being  rolled  up  into  a  small 
spindle-shaped  plug,  about  half  an  inch  long, it  may  be  introduced 
either  by  a  pair  of  forceps  or  threaded  through  a  narrow  silver 
tube.  I  think  it  is  best  to  direct  whatever  form  of  artificial 
membrane  is  used  towards  the  upper  and  posterior  part  of  the 
tympanum,  so  as  to  touch,  if  it  be  present,  the  head  of  the  stapes. 
A  little  pain  is  sometimes  complained  of,  but  if  the  attempt  suc- 
ceeds well  the  patient  is  immediately  conscious  of  hearing  better, 
and  the  cotton  or  disk  should  then  be  left  in  situ  and  the  tube  or 
forceps  carefully  withdrawn.  After  a  little  instruction  from  the 
surgeon,  the  patient  soon  learns  to  apply  it  himself,  and  if  care  is 
taken  to  prevent  accumulation  of  discharge  or  epidermis,  the  eftect 
continues  indefinitely,  and  often  becomes,  even  in  cases  of  other- 
wise extreme  deafness,  so  permanent  as  to  render  the  discontinu- 
ance of  the  wool  possible. 

Thus,  after  careful  local  and  general  treatment,  otorrhoea  may  be 
cured  in  a  few  months.  It  is  always  likely  to  recur  during  child- 
hood and  adolescence,  and  each  recurrence  must  be  treated  like 
the  original  attack.  Symptoms  of  sudden  feverishness  and  head- 
ache, denoting  the  possibility  of  intracranial  inflammation,  may 
come  on  at  any  stage,  and  require  prompt  surgical  assistance.  But 
this  grave  complication  is  very  rare,  considering  the  great  fre- 
quency of  otorrhcea. 

Eczema  of  the  auricle  is  very  common  in  infancy.     It  is  an  un- 


DISEASES   OF   THE   EAE.  715 

sightly  a2ection,and  causes  great  irritation.  It  is  generally  asso- 
ciated with  eczema  capitis,  or  it  maybe  produced  by  the  irritation 
of  dirt  or  of  coarse  soap,  or  of  otorrhoeal  discharge.  The  best  local 
treatment  consists  in  the  application  of  equal  parts  of  glycerin  and 
liquor  calcis  saccharatus.  If  very  obstinate  and  chronic,  a  solu- 
tion of  nitrate  of  silver  will  prove  beneficial.  The  lotion  should 
be  very  dilute  at  first  (gr.  ij  ad  5j),  and  gradually  increased  to 
gr.  X  or  XX  to  the  fluid  ounce.  A  coating  of  vaseline  protects 
the  sore  ear  from  irritation  when  the  child  is  taken  out  of  doors. 
Eut  all  these  applications  are  useless  when  the  rash  arises  from 
constitutional  derangement,  unless  alteratives  be  given,  and  these 
be  followed  by  tonics. 

Abscess,  or  small  imstules  in  the  meatus,  cause  great  suflfering  and 
irritation.  They  arise  from  constitutional  debility,  or  from  the 
irritation  of  injections,  or  the  presence  of  dirty  wool  in  the  meatus. 
The  parents  of  a  child  should  be  directed  never  to  plug  the  ear 
except  when  ordered  to  do  so  by  the  medical  attendant.  They 
should  also  be  reminded  that  the  meatus  must  not  be  washed  out 
with  water,  and  dried  with  the  corner  of  a  towel  forced  into  it. 
Well-intentioned  mothers  and  nurses  often  produce  earache,  inflam- 
mation of  the  meatus,  or  blocking  of  that  passage  by  accumulated 
cerumen,  etc.,  by  this  mistaken  practice.  The  meatus  is  natu- 
rally meant  to  be  dry,  the  cerumen  constantly  falling  oW  in  fine 
powder.  If  it  be  moistened  the  cerumen  cannot  escape  ;  it  accu- 
mulates and  forms  a  moist,  clammy  mass.  It  ultimately  dries, 
sticking  fast  in  the  meatus,  so  that  it  can  only  be  removed  by 
syringing. 

An  abscess  in  the  ear  is  very  painful,  and  must  be  treated  with 
warm  fomentations,  early  incision,  together  with  constitutional 
remedies. 


716  DISEASES    OF    CHILDRE]Sr. 

CHAPTER   LIII. 

DISEASES   OF    THE    SKIN. 

Erythema:  Two  forms  recognized — 1.  Erythema  simplex — 2.  Erythema  nodosum — Use 
of  tonics  and  quinine.  Chilblains  :  Use  of  nitrate  of  silver.  Urticaria  :  Use  of 
quinine  and  arsenic  in  recurring  chronic  attacks.  KosEOLA:  Some  of  its  forms  are 
only  varieties  of  urticaria — Change  of  air,  mild  tonics,  and  sea-bathing  are  serviceable. 
Lichen  :  Value  of  an^enie  in  chronic  cases.  Psoriasis  :  Use  of  arsenic  in.  Eczema 
divided  into  two  forms — 1.  Acute — 2.  Chronic — Treatment  of  both  forms.  Herpes, 
two  forms — 1.  Herpes  labialis — 2.  Herpes  zoster.  Ecthyma. — Impetigo. — Lupus 
VULGARIS :  Rardy  seen  under  tvjo  years  of  age.  Diseases  of  the  Scalp  :  1.  Alopecia 
areata,  or  tinea  decalvans — 2.  Tinea  tonsurans,  or  common  ringworm — Scabies — 
Phihiriasis. 

The  skin  is  supplied  with  bloodvessels,  nerves,  and  glands,  and 
it  performs  a  most  important  part  as  an  exhalant  surface.  It  is  the 
common  seat  of  touch  and  sensation,  and  it  has  direct  relation 
with  the  internal  oro;an8. 

The  skin  is  much  more  susceptible  in  some  persons  than  it  is  in 
others,  and  readil}^  takes  on  morbid  action.  Its  diseases  are 
numerous  and  variable,  some  being  inflammatory,  as  erythema, 
erysipelas,  urticaria,  etc.,  and  others  being  of  a  parasitic  or  con- 
tagious nature.  Some  are  local  and  others  are  constitutional,  each 
demanding  a  separate  line  of  treatment.  Diseases  of  the  skin  are 
of  such  frequent  occurrence,  and  they  come  before  the  practitioner 
so  constantly  in  dailj^  practice  that  he  ought  to  possess  a  fair 
knowledge  of  their  pathology,  diagnosis,  and  treatment. 

The  skin  diseases  of  children  should  be  looked  at  from  a  con- 
stitutional point  of  view,  except  in  specific  afifections.  They  are 
mainly  due  to  malnutrition,  to  errors  of  diet,  to  parasites,  and  fo 
scratching.  I  propose  to  discuss  only  the  most  common  types, 
leaving  the  more  unusual  ones  for  the  specialist  to  deal  with. 

Those  diseases  of  the  skin  in  children  with  which  the  practi- 
tioner most  frequently  meets,  are : 

1.  Those  of  the  general  surface  of  the  body. 

2.  Those  of  the  scalp. 

The  chief  cutaneous  diseases  affecting  the  body  are:  Erythema, 
urticaria,  roseola,  lichen,  psoriasis,  eczema,  lupus  vulgaris,  and 
scabies. 

Erythema  consists  in  inflammation  or  hypersemia  of  the  integu- 
ment, which  disappears  on  pressure,  and  of  some  swelling,  arising 
from  the  exudation  of  serum  into  the  subcutaneous  cellular  tissue. 


DISEASES    OF   THE   SKIN.  717 

The  inflammation  is  superficial,  and  bears  in  a  slight  degree  a 
resemblance  to  erysipelas,  though  it  never  leads  to  destruction  of 
tissue,  as  in  the  latter  affection.  "  The  following  are  the  chief 
points  which  distinguish  erythematous  inflammation:  (1.)  Its 
superficial  character.  (2.)  Its  tendencj^  to  invade  new  tissue,  but 
not  to  return  to  that  previously  affected,  in  which  respect  it  con- 
trasts remarkably  with  eczema.  (3.)  Its  liability  to  attack  sym- 
metrical parts  of  the  body.  (4.)  The  marked  tendency  there  is  to 
slight  cutaneous  hfemorrhage  in  the  course  of  the  inflammatory 
process.     (5.)  The  very  slight  constitutional  disturbance."* 

There  are  only  two  varieties  of  erythema  deservhig  notice  in  a 
work  like  the  present. 

1.  Erythema  Simplex  is  that  wdiich  has  just  been  described. 

2.  Erythema  Nodosum. — In  this  peculiar  affection  oval  and  red 
patches,  varying  from  half  an  inch  to  two  inches  in  diameter, 
having  their  long  axes  downwards,  are  seen  on  the  front  of  the 
legs  in  the  course  of  the  tibia.  They  more  rarely  appear  on  other 
parts  of  the  body.  These  patches  are  swollen  and  elevated  from 
puffiness  of  the  cellular  tissue  beneath,  and  are  very  tender  on 
pressure.  The  patches,  which  at  first  are  red,  gradually  become 
of  a  purple  or  dark  congestive  hue,  in  fact,  passing  through  the 
stages  of  an  ordinary  bruise.  The  constitutional  symptoms  are 
languor,  lassitude,  headache,  disordered  digestion,  pain  in  the 
limbs,  and  slight  febrile  disturbance.  In  some  cases  under  my 
care  it  was  distinctly  associated  with  rheumatism,  but  Dr.  Liveing 
considers  the  articular  pains  not  unfrequently  belong  to  the  disease 
itself.f 

There  is  a  form  of  erythema  due  to  local  caases — erythema  inter- 
trigo^ which  arises  from  the  friction  of  opposed  folds  of  skin,  and 
is  very  common  in  fat  children.  It  is  seen  at  the  upper  parts  of 
the  thighs,  on  their  inner  aspect,  and  between  the  nates.  The 
parts  at  first  become  red,  and  then  a  serous,  or  sero-purulent  dis- 
charge takes  j)lace.  The  treatment  consists  in  the  application  of 
a  little  red  lotion,  or  dusting  the  part  with  starch  or  oxide  of 
zinc  powder.  "  The  saliva  will  often  cause  erythema  around  the 
mouths  of  children,  especially  w^hen  cold  winds  prevail.  There  is 
also  a  chronic  form  of  erythema,  wdiich  is  common  on  the  face 
and  about  the  lips  and  noses  of  children.     This  variety  is  also 

*  Diagnosis  of  Sliin  Diseases,  by  E.  Liveing,  M.D.,  1878,  p.  53. 
t  Op.  cit.,  p.  59. 


718  DISEASES    OF    CHILDREX. 

accompanied  bj  cracking,  wliicb.  is  verj  irritable  and  trouble- 
some."* 

Treatment. — In  severe  cases  this  consists  in  rest  in  bed,  with 
such  remedies  as  correct  the  general  health.  Tonics  are  valuable 
in  erythema  nodosum,  and  quinine  has  in  my  experience  acted  as 
a  specific. 

Chilblains  consist  of  a  localized  erythema  of  the  skin,  chiefly 
affecting  the  hands  and  feet,  as  well  as  some  other  parts  of  the 
bodv  most  distant  from  the  centre  of  the  circulation,  as  the  nose 
and  lobes  of  the  ear.  Among  children  thej^  are  common  in  the 
winter  season  of  the  year  when  the  weather  is  cold.  The  first 
action  of  cold  is  to  produce  a  degree  of  numbness  and  insensibility 
of  the  affected  part,  a  stiffness  in  motion,  and  more  or  less  pallor 
from  an  impediment  to  circulation.  When  reaction  is  established, 
itching  and  tingling  are  experienced  in  the  part,  which  soon  be- 
comes red,  hot,  and  swollen.  An  abrupt  line  marks  the  limit  of 
the  inflammation.  After  the  chilblain  has  continued  a  few  days, 
the  redness  is  exchanged  for  a  bluish  or  livid  appearance,  in  conse- 
quence of  congestion,  dilatation  of  the  capillaries,  and  slowness  of 
the  circulation.     A  chilblain  may,  however,  reach  another  stage. 

Mr.  Erasmus  Wilson  has  described  three  degrees  of  severity: 

1.  The  Erythematous  chilblain. 

2.  The  Vesicated  chilblain. 

3.  The  Gangrenous  chilblain.-f 

1.  The  Erythematous  chilblain  is  that  which  has  just  been  de- 
scribed. 

2.  The  vesicated  or  broken  chilblain  may  be  a  consequence  of  the 
former  variety,  or  arise  from  a  greater  degree  of  cold.  The  itch- 
ing, swelling,  and  congestion  are  greater,  and  the  chilblain  is  of  a 
duskj^  purplish  tint.  The  cuticle  is  raised  b}^  effusion  of  serum 
beneath  which  forms  a  vesicle,  and,  when  it  bursts,  the  surface  is 
livid  or  gray,  exposing  an  ulcerated  or  sloughing  surface.  Such 
chilblains  are  very  tender  and  painful,  the  child  cannot  walk,  and 
if  the  weather  be  severe  and  the  health  impaired,  they  may  last 
all  the  winter. 

3.  The  Gangrenous  Chilblain. — In  this  variety  the  surface  of  the 
skin  is  destroyed  by  the  action  of  the  cold,  gangrene  follows,  and 

\  *  Handbook  of  Skin  Diseases,  by  Dr.  Hillier,  1865,  p.  41. 

f  Diseases  of  llie  Skin,  1SG3,  p.  314. 


DISEASES   OF   THE   SKIN.  719 

a  slough  separates.  Sometimes  the  constitutional  symptoms  are 
severe,  there  is  great  prostration  of  strength,  and,  according  to 
Mr.  Erasmus  Wilson,  the  brain  is  particularly  liable  to  be  atiected, 
and  the  complaint  sometimes  to  end  fatally. 

Treatment. — For  the  ovdaw^vy  erythematous  chilblain, a  mild  stimu- 
lating liniment  of  camphor,  ammonia,  etc.,  will  sometimes  restore 
the  circulation  in  the  affected  part,  or  one  composed  of  soap  lini- 
ment and  tincture  of  cantharidis.  Mr.  Erasmus  Wilson  says : 
"One  of  the  most  useful  remedies  for  the  above  purpose  is  a  lini- 
ment composed  of  the  white  and  yolk  of  two  eggs,  two  ounces  of 
spirits  of  turpentine,  and  two  ounces  of  distilled  vinegar,  well 
shaken  together."*  I  have  never  found  any  remedy  so  uniformly 
successful  as  painting  the  affected  parts  with  a  solution  of  nitrate  of 
silver  (gr.  x-xx  ad  .5j)  night  and  morning,  and  keeping  them  warm 
and  protected  from  the  air.  The  vesicated  and  ulcerated  chilblains 
are  to  be  treated  according  to  their  inflamed  or  indolent  condition. 
If  inflamed,  water  dressing  will  be  of  service,  or  a  lead  lotion;  if 
the  sores  are  torpid,  the  benzoate  of  zinc  ointment,  calamine  oint- 
ment, or  the  resin  ointment,  with  or  w^ithout  spirits  of  turpentine, 
will  be  demanded. 

Urticaria,  or  nettlerash,  is  so  called  from  an  appearance  of  the 
skin  similar  to  that  caused  by  the  sting  of  the  common  nettle. 
Wheals  form  on  the  skin,  accompanied  by  burning  and  stino-lno-j 
and  they  rapidly  disappear  without  desquamation.  They  may  be 
round,  oval,  or  irregular  in  shape,  and  pale  red  or  dusky  in  color. 
Urticaria  often  comes  on  after  a  meal,  accompanied  with  symptoms 
of  indigestion,  weight  and  pain  at  the  epigastrium,  nausea  or  even 
vomiting,  the  eruption  lasting  a  short  time,  and  then  disappearing 
to  recur  again  after  taking  food.  The  disease  is  sometimes  very 
chronic  and  obstinate.  "  It  is  not  uncommon  for  urticaria  to 
occur  in  the  course  of  other  diseases,  febrile  and  nonfebrile.  I  have 
seen  it  during  as  well  as  after  scarlatina,  and  occasionally  in  con- 
nection with  other  exanthemata,  and  whooping-cough. "f  The 
disease  may  be  combined  with  erythema  and  prurigo. 

Causes. — The  disease  may  ai'ise  from  the  stings  of  insects  or 
fleas,  from  mental  emotion,  or  fear,  or  anger,  and  from  certain 
articles  of  diet,  as  shell-fish,  lobsters,  pork,  mushrooms,  cheese, 
etc.     Worms  iii  the  intestinal  canal  are  said  to  produce  it. 

*  Op.  cit.,  p.  315. 

t  Handbook  of  Skin  Diseases,  by  Dr.  Hilller,  1865,  p.  51. 


720  DISEASES    OF   CHILDREN. 

Treatment. — When  the  disease  is  acute.,  and  there  is  gastric  dis- 
turbance, an  emetic  is  the  best  remedy,  followed  by  an  aperient. 
The  diet  should  consist  of  mutton,  milk,  bread,  and  fresh  vegeta- 
bles. Citrate  of  potash,  bicarbonate  of  soda,  and  the  carbonate  of 
ammonia  will  be  useful.  In  the  chronic  form  the  diet  must  be 
carefully  attended  to,  and  the  general  health  looked  after.  Quinine 
and  arsenic  are  of  use  in  recurring  attacks. 

Roseola  or  rose-rash  consists  of  red  spots  of  eruption,  and  is 
frequently  seen  in  infants  and  young  children.  It  resembles  an 
ordinary  inflammation  of  the  skin,  a  state  of  hypersemia  in  which 
the  capillaries  are  more  or  less  distended.  There  is  one  form  called 
Roseola  annulata  consisting  of  red  rings  with  healthy  skin  between 
them ;  when  seen  in  infants  it  is  called  Roseola,  infantilis ;  that 
which  accompanies  the  premonitory  fever  of  variola  is  called 
Roseola  variolosa.,  and  that  following  vaccination  Roseola  vaccinia. 
The  disease  resembles  in  some  instances  measles.,  and  in  others 
scarlatina.,  but  unlike  the  former  affection  the  spots  are  not  elevated, 
and  it  is  usually  limited  to  one  limb,  or  to  the  trunk  of  the  body. 
It  ma}^  disappear  in  a  few  hours  or  last  several  days.  It  is  want- 
ing in  the  bright  scarlet  hue  of  scarlatina.  The  eruption  is  gener- 
ally attended  with  itching.  Many  of  the  so-called  roseolas  are 
only  varieties  of  urticaria. 

The  causes  which  give  rise  to  the  aiiection  are  disturbance  of 
the  digestive  organs,  especially  in  hot  w^eather,  drinking  cold 
water  when  the  body  is  heated,  dentition,  etc. 

Treatment. — The  digestive  organs  must  be  regulated  by  mild 
aperients  and  a  simple  diet.  If  the  gums  are  inflamed  and  tender 
from  the  pressure  of  teeth  they  should  be  lanced.  Change  of  air, 
mild  tonics,  and  sea-bathing  are  serviceable. 

Lichen  is  recognized  hy  numerous  small  red  papules  occurring 
on  any  part  of  the  body  ;  but  the  back  of  the  hands,  the  neck, 
and  the  trunk  are  the  most  frequent  sites.  The  aflfected  parts  itch 
intolerably,  and  at  last  the  papules  desquamate  and  the  eruption 
vanishes. 

In  Lichen  urticatus  the  papules  are  larger,  inflamed,  and  promi- 
nent. They  are  like  the  bite  of  a  gnat  or  bug,  and  the  surface  is 
apt  to  bleed  if  there  is  much  scratching.  "  The  disease  seems  to 
be  peculiar  to  children,  and  is  remarkable  for  its  obstinac3^"* 

Treatment. — This  consists  in  the  administration  of  alkalies  and 

*  Wilson,  On  Diseases  of  the  Skin,  18G3,  p.  101. 


DISEASES    OF   THE   SKIN.  721 

aperients.  For  the  relief  of  itching,  and  to  soothe  irritable  parts, 
lotions  of  borax  and  hydrocyanic  acid  with  glycerin  ;  belladonna, 
and  hydrocyanic  acid,  or  bicarbonate  of  soda  and  hydrocyanic  acid 
are  recommended.  When  the  disease  becomes  chronic,  arsenic 
should  be  given  for  some  time. 

Psoriasis  or  lepra  is  not  common  before  five  years  of  age.  It 
is  characterized  by  small  white  spots  which  increase  in  size  and 
then  run  together,  forming  white  and  scaly  patches.  These  patches 
are  nothing  more  than  layers  of  epidermis.  There  are  neither 
vesicles  nor  pustules.  The  parts  below  the  patella  and  elbow  are 
most  liable  to  be  attacked,  and  sometimes  the  nails.  Two  forms 
are  described.  1.  That  unattended  with  itching.  2.  That  at- 
tended with  itching,  which  is  often  called  gouti/  psoriasis,  and 
rarely  met  with  in  children. 

The  disease  is  said  to  be  hereditary.  It  is  often  seen  in  delicate 
and  cachectic  young  persons  whose  digestion  is  at  fault ;  and  it  is 
exceedingly  liable  to  recur  from  time  to  time.  Indigestion,  con- 
stitutional debility,  rickets,  and  tuberculosis  are  common  causes. 

Treatment. — Eemedies  both  of  an  internal  and  external  character 
are  needed.  A  careful  regulation  of  the  diet  and  attention  to  the 
bowels  are  in  all  cases  demanded.  After  this  arsenic,  as  in  many 
other  chronic  diseases  of  the  skin,  is  useful ;  it  acts  as  a  tonic  and 
alterative.  The  constitutional  efiects  of  the  remedy  are  well 
known,  as  quickness  of  the  pulse,  heat,  and  itching  of  the  eyelids, 
dryness  of  the  throat,  and  a  silvery  film  on  the  tongue.  Sickness 
and  diarrhoea  sometimes  ensue,  and  Avhen  any  of  these  effects  are 
produced,  the  remedy  should  be  discontinued,  at  least  for  a  time. 
Arsenic  should  be  given  after  meals,  either  in  plain  water  or  some 
bitter  infusion,  made  agreeable  by  the  addition  of  a  little  simple 
syrup.  "  Children  bear  arsenic  very  well,  and  one  minim  of  Fow- 
ler's solution  may  be  given  twice  or  three  times  a  day  to  a  child 
of  from  one  to  two  years  old,  and  the  dose  gradually  increased  up 
to  three  minims.  In  the  case  of  infants  at  the  breast,  small  doses 
of  arsenic  may  be  administered  to  the  mother.""^  As  to  local 
treatment  this  is  very  important.  The  scales  when  abundant 
should  be  removed  by  friction  with  soft  soap  and  water,  after  which 
Dr.  Liveing  recommends  the  surface  to  be  dressed  with  tar  oiut- 

*  Notes  on  the  Treatment  of  Skin  Diseases,  by  E.  Liveing,  M.D.,  1875,  p.  61. 

46 


722  DISEASES    OF   CHILDREN. 

ment,*  and  when  the  skin  hecomes  dry  it  shonld  be  smeared  with 
grease  to  keep  it  soft.  "A  solution  of  salicylic  acid  in  alcohol  (1 
in  16),  when  rubbed  over  the  psoriasis  patch,  removes  the  scales 
in  a  few  minutes,  and  then  prepares  the  skin,  for  further  treat- 
ment."f  When  the  joints  are  cracked  and  sore,  the  application  of 
olive  oil  will  be  necessary,  the  limb  being  afterwards  protected 
with  flannel, 

Eczema^  which  is  one  of  the  most  common  diseases  of  the  skin, 
maybe  divided  into:  1.  Acute.  2.  Chronic.  The  acute  variety 
consists  in  an  eruption  of  small  and  slightly  elevated  vesicles, 
situated  on  patches  of  inflamed  skin,  and  attended  with  severe 
smarting  and  itching.  It  is  not  contagious,  but  in  a  pustular 
form,  iiioculable.  The  fluid  contained  in  the  vesicles  becomes 
opaque  and  thick,  then  it  is  discharged  and  dries  into  a  superficial 
yellowish  scab.  The  skin  iinmediately  surrounding  the  affected 
parts  becomes  similarly  involved,  and  vesicles  form  on  it  to  follow 
the  same  series  of  changes.  The  discharge  coming  in  contact 
with  a  scratch  or  sore  may  produce  the  disease. 

According  to  the  late  Dr.  Tilbury  Fox,  vesicles  are  not  alwaj-s 
seen,  but  their  formation  shows  the  "  full  height  of  the  disease 
eczema.":}:  There  is  an  erythematous  eczema,  a  vesicular  eczema, 
a  squamous  eczema,  and  a  pustular  eczema.  He  says  some  eczemas 
are  almost  entirely  local,  being  caused  by  local  irritants,  having 
scarcely  any  inflammatory  action,  and  yielding  to  local  remedies. 
Then  there  are  other  cases  in  which  the  local  mischief  is  severe  ; 
there  is  a  sensation  of  heat,  itching,  and  burning,  the  subcutaneous 
tissue  is  implicated,  and  the  discharge  is  copious  and  irritating  to 
the  parts  around.  "In  a  third  class  of  cases,  occurring  in  young 
and  lymphatic  children,  there  is  very  free  and  early  formation  of 
pus,  out  of  proportion  to  the  degree  of  inflammation,  as  compared 
with  the  last  form  of  eczema,  indicating  a  pyogenic  habit  of  body 
well  marked.  There  is  also  free  crusting,  and  often  distinct  evi- 
dence of  the  scrofulous  diathesis  in  the  family  history.  Now, 
though  these  now  and  then  run  the  one  into  the  other — and  there 
are  no  hard  and  fast  boundary  lines  in    medicine — yet,  on  the 

*  Formula  99 : 

R.  Picis  liqnidse,  vel. 

Olei  nisei, .^ss. 

Glycerini  amyl., oM- — ^^• 

t  The  American  Practitiinier,  Feb.,  1880,  p.  115. 
X  Eczema;  its  Nature  and  Treatment,  1870,  p.  12. 


DISEASES    OF.  THE   SKIX.  723 

whole,  the  distinctions  are  clear,  and  the  terms  simplex,  rnbrnm, 
and  impetiginodes,  accurately  portray  these  clinical  varieties."* 

Children  who  are  subject  to  eczema  are  generally  pale,  thin,  and 
imperfectly  nourished  ;  the  skin  is  dry  and  irritable,  and  the  ner- 
vous system  is  wanting  in  tone.  There  is  also  an  element  of  de- 
bility about  them.  In  1872,  I  had  a  very  obstinate  case  of  sub- 
acute bronchitis  under  my  care,  associated  with  chronic  eczema,  in 
a  child  twenty-one  months  old.  The  child,  who  presented  a  stru- 
mous aspect,  had  all  her  teeth  but  two ;  the  lips  were  thick  and 
•bloodless,  and  the  face,  back  of  hands,  and  the  flexures  of  the 
joints  were  covered  with  an  irritating  eruption.  Under  careful 
medical  and  hygienic  treatment  the  child  eventually  recovered, 
though  for  some  time  after,  exposure  to  cold  brought  on  the  erup- 
tion and  renewed  the  bronchitis.  About  the  same  time  I  saw  a  deli- 
cate boy,  aged  eight,  who  had  subacute  eczema  and  bronchitis  of 
a  tedious  character.  lie  was  treated  carefully  for  two  j^ears,  and 
then  made  a  good  recovery. 

The  treatment  of  acute  eczema  consists  in  the  observance  of  rest 
and  quiet.  As  articles  of  diet,  milk  and  water,  farinaceous  food, 
eggs,  etc.,  should  be  prescribed.  Stimulating  food  and  spirits 
should  be  avoided.  In  the  shape  of  medicines,  sulphate  of  mag- 
nesia, with  a  few  grains  of  nitrate  of  potash  may  be  needed 
(Form.  8).  A  powder  of  scammony  with  calomel,  or  a  little  of 
the  latter  with  the  compound  liquorice  powder  may  be  useful  as 
an  active  purgative.  Cold-water  dressings,  or  the  lotio  plumbi 
are  the  best  applications  when  there  is  heat  and  inflammation. 
They  should  be  changed  as  often  as  they  become  dry.  If  there  is 
great  tingling  of  the  skin,  alkaline  lotions,  or  the  decoction  of 
poppy-heads  may  be  necessary.  It  must  be  borne  in  mind  that 
ointments  are  most  useful  in  the  scaly,  and  lotions  in  the  discharg- 
ing stage.  Fluid  applications  are,  however,  sometimes  difficult  of 
employment  in  young  children,  and  then,  under  these  circum- 
stances. Dr.  R.  Liveing  recommends  that  the  skin  be  powdered 
with  equal  parts  of  oxide  of  zinc  and  starch,  to  which  a  few 
grains  of  powdered  camphor  are  added. f     In  some  cases  linseed- 


*  Op.  cit.,  p.  20. 
t  Formula  100 : 

B.  Zinci  oxyd., 

Pulv.  amyli,  aa      .         ,         .         ,         .         ,         .         .         •     ^ij 

Pulv.  Campliorse, gr.  v. — M. 

To  form  a  powder. 


724  DISEASES   OF   CHILDREN. 

meal  poultices  should  be  afterwards  applied.  When  the  erup- 
tion is  very  irritable,  covering  the  parts  affected  with  benzoated 
zinc  ointment  and  sleeping  in  an  old  linen  shirt  are  advisable. 
The  ung.  plumbi  applied  on  rag  and  kept  on  by  a  bandage  is  very 
serviceable;  it  was  highly  recommended  by  the  late  Dr.  Tilbury 
Fox.  Calamine  and  oxide  of  zinc  form  a  good  lotion  in  acute 
eczema*  In  regard  to  constitutional  remedies,  aperients  and 
alkalies  may  be  required  whilst  the  stage  of  excitement  lasts. 
Later  on,  the  mineral  acids,  with  a  bitter,  are  serviceable  (Form. 
'14-20).  Arsenic,  too,  with  or  without  the  vinum  ferri,  is  useful' 
(Form.  98). 

Chronic  eczema  is  sometimes  a  consequence  of  the  acute  variety. 
The  skin  is  roughened  and  in  a  state  of  chronic  inflammation, 
whilst  at  the  bends  of  the  joints  there  are  cracks  and  fissures  with 
silvery  shining  crusts  upon  them.  The  skin  is  very  irritable  and 
smarting ;  if  the  eruption  be  situated  near  the  vulva  or  anus,  the 
itching  is  distressing,  and  patients  cannot  prevent  scratching  them- 
selves when  warm  in  bed  at  night.  The  disease  may  continue  for 
months  and  years.  I  have  seen  a  few  obstinate  cases  in  young 
children  not  exceeding  seven  years  of  age,  in  whom  the  paternal 
parents,  and  their  ancestors  for  two  or  three  generations,  were 
gouty,  and  some  of  them  had  sutiered  from  eczema. 

Treatment. — Coftee  and  stimulants  should  be  avoided,  and  the 
diet  should  be  light  and  nutritious.  The  bowels  should  be  regu- 
lated by  gentle  aperients,  and  all  sources  of  irritation,  as  worms,  be 
removed.  Arsenic  alone,  or  in  combination  with  iron,  will  be 
found  most  serviceable  (Form.  93).  Cod-liver  oil,  malt  extract, 
etc.,  may  be  given  to  weakly  and  strumous  children.  To  remove 
the  crusts  which  collect  on  the  head  they  should  be  well  moistened 
with  oil,  and  then  a  poultice  of  bread  and  water  applied  afterwards. 
Later  on  the  ung.  hyd.  cum  plumbo,  or  diluted  nitric  oxide  of 
mercury  ointment  with  creasote,  will  be  beneficial. 

Obstinate  and  chronic  as  this  disease  is,  it  is  generally  curable  if- 
the  treatment  adopted  be  judicious,  carried  out  regularly,  and  for  a 

*  Formula  101: 

li.  Pulv.  calam., 

Zinci  oxid.,  aa o'j 

Liq.  calcis, .     3ss. 

Glycerini, 3'J 

Aqua;  rosaj  ad S^j- — •^• 

Fiat  lotio. 


DISEASES    OF    THE    SKIX.  725 

sufficient  length  of  time.  Each  stage  must  be  watched  carefully, 
and  the  treatment  varied  according  as  it  is  inflammatorj^,  vesicular, 
or  squamous ;  in  one  stage  the  skin  is  too  active,  in  the  other  it 
requires  to  be  roused  into  activity  and  energy.  Constipation, 
dyspepsia,  hepatic  disorder,  renal  inadequacy,  and  general  debility, 
have  all  to  be  considered  in  carrying  out  the  treatment. 

Herpes,  or  tetter,  consists  of  a  cluster  of  globular  vesicles  situ- 
ated on  an  inflamed  base,  the  contents  of  which  soon  change  from 
a  clear  to  a  nulky  fluid,  and  then  dry  up,  leaving  a  brown  scab. 
Two  kinds  are  generally  described : 

1.  Herpes  labialis. 

2.  Herpes  zoster. 

1.  Herpes  labialis  is  usually  seen  in  catarrh,  and  in  pulmonary 
aflfections.  It  may  last  two  or  three  weeks,  and  is  unattended  with 
any  constitional  disorder. 

2.  Her-pes  zoster  is  almost  unknown  in  infants  at  the  breast.  It 
is  rare  under  five  years  of  age.  It  is  characterized  by  the  vesicles 
encircling  one-half  of  the  body,  and  being  attended  with  intense 
heat  and  itching,  Severe  neuralgia  sometimes  follows  after  the 
eruption  has  healed. 

The  treatmerd  consists  in  the  use  of  mild  aperients,  -warm  baths, 
and  plain  diet.  Lead  lotion,  and  the  ung.  ziuci  benz.  are  both 
serviceable  for  the  relief  of  pain  and  local  irritation. 

Ecthyma  is  a  disease  in  which  large  yjustules  form  situated  on  an 
inflamed  portion  of  the  skin.  They  break  and  dry  into  thick  scabs, 
and  when  thej^  fall  oft"  there  is  ulceration  beneath.  When  this  has 
healed  the  neighboring  skin  is  of  a  purplish  tint.  The  disease  is 
seen  in  strumous  and  badly  nourished  children,  and  it  is  an  occa- 
sional sequela  of  scarlatina  and  measles.  The  disease  may  be 
acute  or  chronic.  The  acute  form  of  the  aiiection-  is  attended 
with  slight  febrile  disturbance,  headache,  loss  of  appetite,  heat,  and 
itching.  It  may  last  two  or  three  weeks.  Tartar  emetic  ointment 
produces  a  similar  eruption.  The  chronic  form  is  often  seen  in 
delicate  infants  and  young  children.  There  is  no  fever  and  no 
pain.  The  pustules  are  very  large,  and  successive  crops  may  spring 
up,  and  continue  for  two  or  three  mouths. 

Treatment. — The  scabs  should  be  removed  by  poulticing,  or 
moistening  with  warm  oil.  The  ulcers  should  be  dressed  with  lead 
lotion,  or  water-dressing  if  inflamed,  and  if  indolent  with  the  nitric 


726  DISEASES    OF   CHILDREN. 

oxide  of  mercury  ointment,  or  some  similar  application.  Good 
food,  cod-liver  oil,  mild  aperients,  will  be  needed.  The  mineral 
acids  and  bark,  the  vinum  ferri  and  arsenic  (Form.  93),  are  also 
serviceable. 

Impetigo. — This  disease  is  more  common  than  that  which  has 
just  been  described  (ecthyma).  In  most  cases  these  are  forms  of 
pustular  eczema.  The  disease  consists  in  the  appearance  of  small 
pustules,  which  come  to  maturity  in  the  course  of  a  day  or  two. 
They  then  burst  and  discharge  thick  pus,  which  becomes  trans- 
formed into  a  browish-yellow  scab.  Pus  often  continues  to  ooze 
from  under  the  scab  or  crust,  and  when  the  scab  finally  separates, 
a  red  mark  is  left. 

Impetigo  may  be  seen  on  the  arms,  legs,  face,  or  scalp.  "  When 
it  attacks  the  face  of  children  it  is  known  as  crusta  ladea."* 

The  disease  is  generally  due  to  debility,  and  is  of  frequent  occur- 
rence in  children.  Pediculi  of  the  head  by  causing  irritation  may 
excite  it. 

Treatment. — The  diet  should  be  plain,  simple,  and  nutritious, 
all  stimulants  being  avoided.  Aperients,  followed  by  tonics,  as 
quinine,  will  be  serviceable,  and  if  the  disease  threatens  to  be- 
come chronic,  iodide  of  potassium  with  bark  will  be  necessary, 
and  baths  to  improve  the  state  of  the  skin.  Locally,  poultices 
to  remove  crusts  will  be  required,  and  the  sores  should  be  dressed 
with  dilute  citrine  ointment,  or  the  white  precipitate  ointment. 

Lupus  vulgaris  is  a  chronic  disease  of  the  skin,  non-contagious, 
and,  though  common  in  early  life,  is  rarely  seen  in  children  under 
two  years  of  age  (Liveing).  It  usually  attacks  the  face,  and  more 
particularly  the  nose,  but  it  may  occur  on  any  part  of  the  body. 
It  begins  with  small  reddish  tubercles,  which  increase  in  size,  and 
then  ulcerate.  The  disease  is  associated  with  the  strumous  diathe- 
sis. It  may  be  mistaken  for  s^^philis,  and  in  older  persons  it  has 
been  confounded  with  cancer. 

Treatment. — This  consists  primarily  in  constitutional  measures, 
fresh  air,  animal  food,  and  a  liberal  diet,  of  which  milk  should 
form  a  chief  part.  In  respect  to  medicines,  cod-liver  oil  is  most 
essential,  and  iron  and  arsenic  are  valuable  remedies.  The  local 
treatment  consists  in  the  application  of  some  caustic,  as  the  acid 
nitrate  of  mercury. 

*  Hillier,  op.  cit.,  p.  163. 


DISEASES    OF    THE   SKIN.  727 

Diseases  of  the  scalp  may  be  thus  arranged : 

1.  Alopecia  areata,  or  tinea  decalvans. 

2.  Tinea  tonsurans,  or  common  ringworm. 

1.  Alopecia  areata  is  a  non-parasitic  disease;  it  consists  of  an 
atrophied  state  of  the  roots  of  the  hair,  which  terminates  in  bald- 
ness. The  hair  first  becomes  dry,  and  then  it  withers  and  falls 
oft",  leaving  white  and  smooth  circular  patches.  The  most  com- 
mon site  is  the  scalp. 

As  to  the  pathology  of  the  aftection,  a  fungus  was  formerly  be- 
lieved to  be  developed  within  the  follicles  of  the  roots  of  the  hair, 
composed  of  small,  round,  oval  spores,  which  form  into  a  layer  at 
the  roots  of  the  hair,  and  then  spread  to  the  cuticle.  This  view  is 
now  rejected  by  the  most  competent  observers. 

Treatment. — This  is  very  unsatisfactory ;  but  painting  the  af- 
fected parts  with  tincture  of  iodine  once  or  twice  a  day,  or  occa- 
sionally blistering  with  the  fluid  blister  of  the  Pharmacopoeia, 
often  brino-s  about  a  cure.  Dr.  Hillier  recommended  rubbing  the 
bald  parts  with  a  liniment  composed  of  equal  parts  of  tincture  of 
cantharides  and  olive  oil.  Strong  carbolic  acid  is  an  excellent 
application. 

2.  Tinea  Tonsurans  (ringworm  of  the  scalp). — In  this  disease  the 
roots  of  the  hair  become  mouldy,  and  at  last  break  away  near  the 
surface  of  the  skin.  The  hairs  are  brittle  and  thickened,  readily 
breaking  at  the  roots,  which  present  a  split  and  ragged  appear- 
ance. Dry,  scaly,  and  circular  patches  form,  varying  from  half  an 
inch  to  three  or  four  inches  in  diameter.  Vesicles  are  also  some- 
times seen,  and  a  viscid  fluid  escapes  from  the  follicles.  This  dis- 
ease is  contagious,  and  its  origin  depends  on  a  fungus  with  oval 
or  rounded  spores 

Treatment. — The  same  as  that  recommended  for  the  previous 
disease  in  an  early  stage.  Later  on,  if  it  does  not  yield,  a  fairly 
strong  citrine  ointment,  night  and  morning,  will  cure  most  cases. 
Carbolic  acid,  or  the  carbolized  glycerin  of  the  Pharmacopoeia,  are 
useful.  But  the  aftection  is  almost  always  tedious,  and  if  a  cure 
is  eftected  in  three  months  the  treatment  may  be  considered  sat- 
isfactory. 

Scabies,  psora,  or  itch,  is  a  disease  arising  from  the  acarus  scabiei 
(itch  mite)  burrowing  beneath  the  cuticle,  and  there  depositing  its 
eggs.     It  may  be  seen  in  this  situation  as  a  small  body,  the  skin 


728  DISEASES   OF    CHILDREN. 

presenting  at  the  point  of  entrance  a  papular  elevation.  The  spot 
usually  seen  is  beneath  the  skin  between  the  fingers  and  toes,  at 
the  bend  of  the  elbow,  the  axilla,  and  behind  the  knee ;  but  it  may 
attack  any  part  of  the  body,  especially  in  children.  When  the 
vesicle  is  broken,  scabs  or  crusts  are  formed.  In  these  crusts 
young  animals  are  contained.  The  irritation  or  scratching  may 
occasion  various  forms  of  eczema  and  urticaria,  aceordins  to  Dr. 
Liveing,  especially  in  long-standing  cases  in  children. 

Treatment. — The  child  should  have  a  warm  bath  before  going  to 
bed,  and  be  washed  wath  soap  and  flannel.  After  being  well 
dried  he  should  have  the  sulphur  and  potash  ointment*  rubbed 
into  him.  He  should  then  be  clothed  with  flannel,  and  wear  gloves 
and  socks,  to  prevent  the  application  from  rubbing  off.  The  next 
night  the  process  should  be  repeated,  and  it  may  be  necessary  to 
repeat  it  for  a  third  night.  A  sulphur  bath  is  also  an  excellent 
remedy,  and  may  obviate  the  use  of  the  ointment  altogether. 

Fhthiriasis — Lousiness. — This  disease  arises  from  lice  being  situ- 
ated on  the  body.     The  most  common  sites  are : 

1 .  The  head  {Pediculus  capitis). 

2.  The  body  ( Pediculus  corporis). 

3.  The  pubis  [Pediculus  pubis). 

The  eggs,  which  are  known  as  nits,  bite  the  skin,  and  produce  a 
pustular  eruption  and  insufferable  itching. 

The  treatment.,  which  is  always  effectual,  consists  in  rubbing  in 
mercurial  ointment  or  the  white  precipitate  ointment.  A  few 
applications  generally  suffice  for  a  cure.  For  Pediculi  corporis., 
Btaphisagra  ointment  (Squire's  formula)  is  the  best  and  safest. 

*  Ung.  Pot.  Snlph.,  B.  P. 


FORMULA 


NO.  .  FORM.     PAGE. 

1.  Saline  aperient,      ...........       1         40 

R.  Magnes.  sulph.,  5J 
Tinct.  rbei.,  ^ss.  vel 
Syr.  rliei,  ^ss. 
Syr.  zingib.,  ^ij 
Tinct.  cinnamomi,  ^j 
Aquam  anethi  ad  5ij. — M. 
One  to  two  teaspoonfuls  to  be  taken  at  bedtime  and  in  tbe  early  morning.    For  chil- 
dren from  six  to  twelve  months  old. 

2.  Saline  aperient,       ...........       8       109 

R.  Magnes.  sulph.,  ,^j 
Potass,  nitrat..  ^ss- 
Syr.  limonura,  vel 
Syr.  tolut.,  5iij 
Aquam  ad  giv. — M. 
A  tablespoonful  every  four  hours.     For  a  child  five  or  six  years  old. 

3.  Saline  aperient,      ...........     41       203 

R.  Magnes.  sulph.,  giss. 
Syr.  rhei,  3ss. 
Tinct.  cinnamomi,  ^ss. 
Liq.  magnes.  carb.  ad  ^iss. — M. 
One  or  two  teaspoonfuls  occasionally.     For  children  from  six  to  twelve  months  old. 

4.  Laxative  in  constipation  and  irritable  diarrhoea,       .         .         .         .         .23       184 

R.Ol.  ricini,  §ss. 
Magnes.  carb.,  ^ij 
Sacchari,  ^iij 
01.  anisi,  TTjjij.— M. 
A  teaspoonful  for  a  dose. 

5.  Laxative, 39       203 

R.  Mannse  opt.,  ^ij 

Aquam  anethi,  5].— M. 
A  teaspoonful  once  in  two  or  three  hours  till  the  bowels  act.  For  children  from  four 
to  six  months  old. 


730  FOEMUL^. 

>-0.  FORM.     PAGE 

6.  Laxative, 40      203 

R.  Potass,  bitart.,  ^ss. 
Mannse,  §ss. 

Aquam  anethi  ad  §iss. — M. 
About  gr.  X  or  gr.  xv  for  a  dose,  to  be  repeated  occasionally.     For  children  from 
four  to  six  months  old. 


7.  Aperient, 84      632 

R.  Potass,  sulphat.,  gr.  x 
Pulv.  rhei,  gr.  iv. — M. 
To  be  taken  in  the  early  morning.     For  a  child  ten  years  of  age. 


8.  Aperient  and  tonic,         ..........     97       701 

R.  Magnes.  sulph.,  gr.  xvj 
Acid,  sulph.  dil.,  ^r^iij 
Ferri  sulph.,  gr.  iv 
Vel.  tinct.  ferri  perch.,  "^xl 
Syr.  zingib.,  gij 
Aquam  carui  ad  ^iv. — M. 
A  dessertspoonful  three  times  a  day.     For  children  from  five  to  ten  years  of  age. 

9.  In  some  forms  of  diarrh(Ba,    .         .         .         .         .         .         .         .         .     24       1 85 

R.  01.  ricini,  gss. 
T.  opii,  n^yj 
Mucilag.,  ^ij 
Syr.  zingib.,  giij 
Aquam  anethi  ad  ^iss. — M. 
One  teaspoonful  to  be  given  occasionally.     For  children  from  six  to  twelve  months 
old. 


10.  Astringent, 4         91 

K.  Tinct.  kramerise,  ^iij 
Liquor,  opii  sed.,  "Kxij 
Spt.  chloroform.,  ^xx 
Syr.  zingiberis,  ,^ss. 
Aquam  ad  ^iv. — M. 
A  dessertspoonful  after  each  action  of  the  bowels.     For  children  from  five  to  eiglit 
years  of  age. 

11.  Astringent, 16       146 

R.  Pulv.  cretse  c.  opio,  ^ij 
Tinct.  catechu,  ^ij 
Aquam  menth.  pip.  ad  ^ij. — M. 
Two  teaspoonfuls  after  eacli  action  of  the  bowels.     For  children  five  years  of  age. 


FOEMUX,^.  731 


FOEM.     PAGE 


KO. 

12.  Astringent, 28       191 

R.  Acid,  gallic,  gr.  viij 
Tinct.  cinnamomi,  gj 
Tinct.  opii,  Tr^iv 
Syrupi,  3ij 
Aquae  cinnamomi,  ^v 
Aquam  ad  ^ij. — M. 
Two  teaspoonfuls  every  four  hours.     For  children  a  year  old. 


13.  Astringent, 29       191 

B.  Plumbi  acetat.,  gr.  vj 
Aceti,  ■"j^xx 
Tinct.  opii,  Ti^viij 
Mucilag.  acaciae,  ^ij 
Syr.  zingib.,  3J 
Aquam  ad  ^ij. — M. 
Two  teaspoonfuls  every  six  hours.     For  children  a  year  old. 


14.  Astringent, 30       191 

R.  Tinct.  opii,  -"^vj 
Tinct.  card,  co.,  3J 
Syrupi,  gij 

Decoct,  hsematoxyli  ad  ^iss. — M. 
A  teaspoonful  every  four  hours.     For  children  a  year  old. 


15.  Astringent, 31       192 

R.  Tinct.  catechu,  3J 
Syr.  zingib.,  ^ij 
Mist.  cretEe  ad  ^iss. — M. 
A  teaspoonful  every  four  hours.     For  children  a  year  old. 


16.  Astringent, 33       192 

R.  Acid,  nitric,  dil.,  ""^xxiv 
Tinct.  camph.  co.,  5J 
Spt.  chloroform.,  irj^sij 
Syr.  zingib.,  ^ij 

Decoct,  hsematoxyli  ad  ^iss. — M. 
A  teaspoonful  every  four  hours.     For  children  a  year  old. 


17.  Astringent, 34       192 

R.  Acid,  sulph.  dil.,  ,^ss. 
Spt.  chloroform.,  ^r^xx 
Syrupi,  ^ij 
Aquam  ad  §iss. — M. 
A  teaspoonful  every  four  hours.     For  children  a  year  old. 


732  FORMULA. 

jjQ  FORM.     PAGE 

18.  Astringent, 35       192 

R.  Acid,  nitric,  dil.,  tt^xx 
Syr.  gummi  rubr.,  J^ij 
Spt.  chloroform.,  n^xx 
Decoct,  hsematoxyli  ad  ^iss. — M. 
A  teaspoonful  every  four  hours.     For  children  a  year  old. 


19.  Astringent, ^^       -^^^ 

R.  Ext.  belse  liquid.,  §ss. 
Syr.  gummi  rubr.,  ^ij 
Tinct.  camph.  co.,  3J 
Syr.  zingib.,  ^ij 
Aquam  ad  ^iss. — M. 
A  teaspoonful  three  or  four  times  a  day.     For  children  six  years  of  age. 


20.  Astringent, 37       192 

R.  Cupri  sulph.,  gr.  ij 
Liq.  opii  sed.,  TTjjxxiv 
Spt.  chloroform.,  3j 
Aquam  cinnamomi  ad  ,^iij. — M. 
Two  teaspoonfuls  three  times  a  day.     For  children  six  years  of  age. 


21.  In  round-worm, • 48       307 

R.  Santonin,  gr.  iv-vj 
Sacchari,  gr.  ij 
Fiat  pulvis. 
To  be  taken  every  third  night. 


22.  In  round-worm,,  .......••••     49       307 

R .  Santonin,  gr.  ij 

Pulv.  scammonii  co.,  gr,  v 
Fiat  pulvis. 
To  be  taken  at  bedtime. 


23.  In  round-worm,  ...........     50       307 

R .  Santonin,  gr.  xv 
Pulv.  zingib.,  gr.  v 
Pulv.  jalapse,  ^ss. 
Sulphuris  loti,  ^iss. 
Conf.  sennae,  5J. — M. 
3j  three  times  a  day. 


FORMULA.  733 

NO.  FORM.      PAGE 

24.  In  tapeworm,         ...........     51       308 

R.  Ext.  filicis  liquid.,  ^ss.-^j 
Syr-  zingib.,  3j 
Pulv.  acacise,  gr.  x 
Aquam  cinnamomi  ad  ^j.— M. 
Fiat  tiaustus.     For  a  child  from  five  to  ten  years  old. 

25.  In  ascarides,         ...........     SS       194 

R.  Ferri  sulphat.,  5j 

Inf.  quassise,  ^viij. — M. 
Fiat  enema.     A  fourth  part  to  be  used  every  morning. 

26.  In  ascarides,         ...........     46       304 

R.  Sodii  chlorid.,  vel 
Ferri  sulph.,  3j 
Inf.  quassise,  Oj 
Fiat  enema.     A  third  part  to  be  used  every  morning. 

27.  In  ascarides,        ...........     47       304 

R .  Liquor  calcis,  ^  vj 
Fiat  enema.     To  be  used  every  morning. 

28.  Tonic  in  some  states  of  typhoid  fever,      .......       6         91 

R.  Quinise  sulph.,  gr.  iv 
Acid,  phosph.  dil.,  ^j 
Syrupi,  ^ss. 
Aquam  ad  §iv. — M. 
A  dessertspoonful  three  or  four  times  a  day.     For  children  from  five  to  eight  years 
of  age. 

29.  Tonic, 11       133 

R.  Amm.  carb.,  gr.  viij 
Tinct.  cinch,  comp.,  ^ij 
Syi.  aurant.,  ^iij 
Aquam  ad  5! v. — M. 
A  dessert  or  tablespoonful  every  four  hours-     For  a  child  four  or  five  years  old 

30.  Tonic, 14       145 

R.  Acid,  nitric,  dil. 

Acid  hydrochl.  dil.,  aa  ^ss. 
Tinct.  cinch,  co.,  vel 
Tinct.  calumbse,  ^iij 
Syrupi,  ^ss. 
Aquam  ad  §iv. — M. 
A  tablespoonful  three  times  a  day.     For  children  five  years  of  age. 


734  FOEMUL,^. 

KO.  FORM.     PAGE 

31.  Tonic, 20       173 

R.  Acid.  nit.  dil.,  "^xij 

Acid,  hydroch.  dil.,  ^xxiv 
Tinct.  calumbse,  3j 
Syr.  aurant,  ^ij 
Aquam  ad  §ij. — M. 
5j  ter  die.     For  children  a  year  old. 


32.  Tonic, 22       173 

B.  Tinct.  cincho.  co.,  giss. 
Acid,  nucis  vom.,  "J^xij 
Syrupi,  ^ij  ^ 
Aquam  ad  ^iss. — M. 
3j  ter  die.     For  children  a  year  old. 


33.  Tonic, 53       352 

R .  Tinct.  ferri  perchlor.,  3J 
Glycerini,  §ss. 
Aquam  ad  ,^iv. — M. 
A  tablespoonful  every  four  hours.     For  children  five  years  of  age. 


34.  Tonic, •    54      352 

R.  Tinct.  ferri  perchl.,  "^xl 
Potass,  chlorat.,  gr.  xl 
Acid,  hydrochl.  dil.,  Tr)jxl 
Syrupi  hydrochl.  dil.,  §S8. 
Aquam  ad  giv. — M. 
A  tablespoonful  every  four  hours.     For  children  five  years  of  age. 


35.  Tonic  in  some  forms  of  catarrh,       ........     68       426 

ij.  Syr.  ferri  iod.,  ,^ss. 
Vin.  ipecac,  3j 
Aquam  ad  §iij. — M. 
Two  teaspoonfuls  three  times  a  day.     For  children  five  or  six  years  old. 


36.  Tonic  in  some  forms  of  pneumonia, 69      464 

R.  Amra.  carb.,  gr.  viij 
Tinct.  quinise,  ^iij 
Spt.  chloroform.,  ^xx 
Syr.  tolut.,  5iij 
Decoct,  senegse  ad  ^iv. — M. 
A  tablespoonful  every  four  hours.     For  children  five  or  six  years  old. 


FORMULiE.  735 

NO.  FOEM.     PAGE. 

37.   Tonic  in  tuberculosis  and  phthisis,  '.         .         .         .         .         .         .73       499 

B.  Calcis  hj'pophosphitis,  Qij 
Tinct.  ferri  perchl.,  giss. 
Quiniae  sulph.,  gr.  vj 
Liquor  strychnise,  tt^xx 
Syrupi,  gj 

Aquam  ad  ^vj. — M. 
A  tablespoonful  three  times  a  day. 


38.  Tonic  in  phthisis, ....     80       528 

R.  Tinct.  ferri  perchl.,  gj 
Calcis  hypophosphitis,  ^ss. 
Glycerin i,  ^iij 
Aquam  ad  ^vj. — M. 
A  tablespoonful  three  times  a  day. 

39.  Tonic  in  phthisis,  ......  ....     81       528 

R.  Sodse  hypophosphitis,  ^ss. 
Acid,  phosph.  dil.,  ^ij 
Tinct.  quinise, 
Glycerini,  aa  ^ss. 
Inf.  aurant.  co.  ad  ^vj. — M. 
A  tablespoonful  three  times  a  day,  with  one  teaspoonful  of  cod-liver  oil.     For  chil- 
dren from  ten  years  of  age  and  upwards. 


40.  Tonic, 94      699 

B .  Ferri  redacti, 
Sacchar.  pur., 

Pepsinse  porci,  aa  gr.  ij. — M. 
To  be  taken  twice  a  day  after  food.     For  children  ten  years  of  age. 


41.  Tonic, 95      700 

R.  Ferri  et  amm.  citr.,  gr.  xvj 
Amm.  carb.,  gr.  viij 
Syrupi,  giij 
Aquam  ad  5  iv. — M. 
A  dessertspoonful  three  times  a  day. 

42.  Tonic, 96      700 

R.  Tinct.  ferri  perchlor.,  i^xl 
Glycerini,  ^iij 

Aquam  cinnamomi  ad  §iv. — M. 
A  dessertspoonful  three  times  a  day.     For  children  from  five  to  ten  years  of  age. 


736  FOEMULiE. 

NO.  FORM.     PAGE 

43.  Tonic 98       701 

R.  Tinct.  belladonnse, 

Tinct.  ferri  perclilor.,  aa  tr^xl 
Spt.  chloroform.,  "^xvj 
Glycerini,  ^iij 
Aquam  ad  ^  iv. — M. 
A  dessertspoonful  three  times  a  day.     For  children  from  five  to  ten  years  of  age. 


44.  Tonic  and  sedative  in  epilepsy,        ........     82       604 

R.  Ferri  et  amm.  citr.,  gr.  xvj 
Potass,  bromid.,  Qij 
Syrupi,  giij 
Aquam  ad  ^iv. — M. 
A  tablespoonful  three  times  a  day.     For  children  from  six  to  twelve  years  of  age. 

45.  Tonic  and  sedative  in  epilepsy, 83       606 

R.  Tinct.  digitalis,  "Xxx-uKxI 
Potass,  bromid.,  Qij 
Syrup,  aurant.,  giij 
Aquam  ad  ^iv. — M. 
A  tablespoonful  three  times  a  day.    For  children  from  six  to  twelve  years  of  age. 


46.  Tonic  and  alterative, 93       682 

R.  Vin.  Ferri,  .^iss. 
Syr.  tolut.,  3iij 
Liq.  fowleri,  gj 
Aquam  ad  ^iv. — M. 
A  teaspoonful  in  a  tablespoonful  of  water  twice  a  day  after  food.     For  a  child  from 
five  to  ten  years  of  age. 

47.  Sedative  in  cerebral  irritation,         ,         .        .        .        .        ,         .         .3        72 

R.  Potass,  bromid.,  gr.  xx. 
Potass,  iodidi,  gr.  iij 
Spt.  amm.  arom.,  ttjJxx 
Syrupi  amm.  arom.,  3iij 
Aquam  ad  ,^iss. — M. 
A  teaspoonful  to  be  taken  every  four  hours.     For  children  a  year  old. 


48.  Sedative  in  cystitis, 45       286 

R.  Liquor,  potass.,  3J 
Liquor  opii  sed.,  ^viij 
Mucilag.,  ,^ss. 
Mist.  Camph.,  ad  ,51  v. — M. 
A  tablespoonful  every  four  hours.     For  a  cliild  eight  or  ten  years  old. 


FORMULA.  737 

NO.  FORM.     PAGE. 

49.  Sedative  in  laryngismus,  .........     56       365 

K.  Potass,  bromid.,  3j 

Tinct.  quinise,  ^iss.  ' 

Glycerin!,  ^ij 
Aquam  ad  ^iij. — M. 
A  teaspoonful  three  times  a  day.     For  a  child  one  year  old. 


50.  Sedative  in  whooping-cough,    .........     57       379 

R.  Ext.  belladonnse,  gr.  j 
Aluminis,  ^ss. 
Syr.  zingib. 
Syr.  acacise, 
Aquae,  aa  3J.— M. 
3j  four  times  in  the  twenty-four  hours.     For  a  child  a  year  old.      (Meigs  and  Pep- 
per.) 

51.  In  whooping-cough,         ..........     58       380 

R.  Cocci,  gr.  V 

Potass,  bicarb.,  gr.  xl 
Syrupi,  gss. 
Aquam  ad  §iv. — M. 
A  dessertspoonful  every  three  or  four  houi-s.     For  a  child  two  years  old. 


62.  Sedative  and  tonic  in  whooping-cough,     .......     59       382 

B .  Tinct.  quinise,  3ij 
Potass,  bromid.,  gr.  xl 
Glycerini,  gss. 
Aquam  ad  ^iv. — M. 
A  dessertspoonful  three  times  a  day.     For  a  child  five  years  old. 


53.  Stimulant  in  some  forms  of  pneumonia, 71       469 

R.  Tinct.  cinch,  co.,  ^iiss 
Amm.  carb.,  gr.  viij 
Tinct.  camph.  co.,  i^xl 
Syr.  tolut.,  3iij 
Aquam  ad  ^iv. — M. 
A  dessertspoonful  every  four  hours.     For  children  five  or  six  years  old. 


54.  Stimulant  and  tonic  in  some  foi'ms  of  pneumonia,     .         .         .         .         .72      469 
R.,Ferri  et  amm.  citr.,  gr.  xij 
Amm.  carb.,  gr.  viij 
Potass,  iodidi,  gr.  iv 
Syrupi,  ^ij 
Aquam  ad  5iv. — M. 
A  dessertspoonful  to  be  taken  three  times  a  day.     For  children  five  or  six  years  old. 

47 


738  FORMULA. 

jjO,  FORM.     PAGE. 

55.  Stimvlaiing  expectorant  in  pneumonia, 70      465 

R.  Amm.  carb.,  gr.  viij 
Potass,  bicarb.,  ^ij 
Vin.  ipecac,  ''^xl 
Syr.  tolut.,  .^iij 
Aquam  ad  3iv. — M. 
A  tablespoonful  every  four  hours.     For  children  five  or  six  years  old. 


56.  In  some  forms  of  bronchitis, 65       424 

R .  Potass,  citrat.,  vel 
Potass,  bicarb.,  ^ss. 
T.  camph.  comp. 
Vin.  ipecac,  aa  .5J 
Syr.  scillse,  ,^ss. 
Aquam  ad  ,f  ij. — M. 
A  teaspoonful  every  three  hours.     For  children  from  one  to  two  years  of  age. 

57.  In  some  forms  of  bronchitis,    .........     66      425 

R.  Vin.  ipecac, 

Tinct.  scillse,  aa  ^xl 
Tinct.  conii,  3j 
Spt.  aether,  nit.,  gj 
Syr.  tolut.,  ^^ss. 
Decoct,  senegas  ad  ,f  iv. — M. 
A  dessertspoonful  every  four  hours.     For  children  from  five  to  eight  years  of  age. 

58.  In  chronic  bronchitis, 67       426 

R.  Amm.  carb.,  gr.  viij 
Tinct.  cinch,  co.,  ^ij 
Syr.  tolut.,  ,f  ss. 
Aquam  ad  §iv. — M. 
A  dessertspoonful  three  or  four  times  a  day.     For  children  five  or  six  years  old. 

59.  In  bronchitis, 61       423 

R.  Amm.  carb.,  gr.  iv 
Spt.  chloroform.,  ^xx 
Syr.  tolut.,  5ss. 
Aquam  ad  .fij. — M. 
A  teaspoonful  every  four  hours.     For  a  child  a  year  old. 


60.  In  catarrh  and  bronchitis, 63       424 

R.  Syr.  tolut., 
Syr.  scillse, 
Aquam,  aa  f  ss. — M. 
A  teaspoonful  when  the  cough  is  troublesome. 


FORMULAE.  739 

NO.  FORM.     PAGE. 

61.  In  catarrh  and  bronchitis,       .........     64      424 

R.  Syr.  tolut., 
Syr.  scillse, 
Senna,  aa  ^ss. — M. 
A  teaspoonful  twice  or  three  times  a  day,  or  when  the  cough  is  troublesome. 

62.  In  the  cough  of  phthisis, .         .74       525 

R.  Syr.  papav., 
Scillse, 

Limonum,  aa  ^ss. — M. 
3j  pro  re  nata. 

63.  In  the  cough  of  phthisis, .75       526 

R.  Morph.  acet.,  gr.  ^ 

Acid,  hydrocy.  dil.,  ^xvj 
Glycerini,  ^ij 
Aquam  ad  ^iss. — -M. 
3j  pro  re  nata. 
For  children  from  five  to  ten  years  old. 

64.  In  some  forms  of  bronchitis  and  catarrh,  ......     60       423 

R.  Liquor,  amm.  acet.,  ,^ss. 
Acid,  hydrocy.  dil.,  Ti^viij 
Vin.  antimonialis,  Tr)^xl 
Syr.  scillBe,  .^ss. 
Aquam  ad  ^iv. — M. 
A  dessertspoonful  every  four  hours.     For  a  child  five  or  six  years  old. 

65.  Saline  depressant  in  febrile  states,    ........     62       423 

R.  Hydr.  chlorid.,  gr.  ij 

Pulv.  antimonialis,  gr.  viij 
Potass.,  nitrat. 
Sacchari,  aa  gr.  xij. — M. 
Ft  divide  in  pulveres  iv.   One  every  four  or  six  hours.     For  a  child  from  five  to  ten 
years  old. 

66.  In  some  forms  of  diarrhoea,     .........     27       l87 

R.  Magn.  sulph.,  3ss. 
Tinct.  rhei,  3j,  vel 
Syr.  rhei,  ^ij 
Tinct.  quinife,  ^ss. 
Aquam  menth.  pip.  ad  ,^iss. — M. 
A  teaspoonful  every  four  hours.    For  children  from  one  to  two  years  old. 

67.  Carminative  and  aperient,       .........     26       187 

R.  Pulv.  rhei, 

Sodse  bicarb.,  aa  gr.  xij 
Spt.  amm.  arom.,  ii;^xx 
-  Syr.  zingib.,  ^iij 

Aquam  menth.  pip.  ad  ^iss. — M. 
A  teaspoonful  every  four  hours.     For  children  a  year  old. 


740  FOEMUX^, 

NO.  FOESI.     PAGE. 

68.  Alterative  and  tonic  in  sluggish  liver, 42       204 

R.  Acid,  nitric  dil.,  ^D^xvj 
Acid  hydrochl.  dil.,  gss. 
Succi  taraxaci,  ^j 
Syr u  pi,  §ss. 
Aquam  ad  ^iv. — M. 
A  dessertspoonful  three  times  a  day.    For  a  child  three  or  four  years  old. 


69.  In  diarrhosa, 25       185 

B.  Sodse  bicarb.,  gr.  xij 
■Liq.  bismuth.,  ^ij 
Mucilag.,  5ij 
Syr.  zingib.,  ^ss. 
Liq.  magnes.  carb.,  §iv. — M. 
A  dessertspoonful  three  times  a  day.     For  a  child  two  years  old. 


70.  In  vomiting  and  flatulence, 2         71 

B.  Acid,  hydrocy.  dil.,  fi^vj 
Spt.  amm.  arom.,  tt^xx 
Syrupi.  amm.  arom.,  §ss. 
Liquor,  magn.  carb.  ad  ^iss. — M. 
A  teaspoonful  to  be  taken  every  four  hours.     For  children  a  year  old. 


71.  In  typkoidjever,       .         .        ' i         .         .         .       5       91 

R.  Acid,  hydrochl.  dil.,  fr^xl 
Spt.  chloroform.,  n;^xx 
Syr.  rosae,  ^ss. ' 
Aqnam  ad  giv. — M. 
A  dessertspoonful  every  four  hours.     For  children  from  five  to  eight  years  of  age. 

72.  In  some  febrile  states,     .    ' 7       109 

R.  Liquor,  amm.  acet.,  §ss. 
Yin.  antimonialis,  tt^xI 
Syr.  tolutani,  ^iij 
Aquam  ad  §iv. — M. 
A  tablespoonful  every  four  hours.     For  a  child  five  or  six  years  old. 


73.  In  scarlatina, .       9       111 

R.  Potass,  chlorat.,  gr.  xx 
Acid,  hydrochl.  dil.,  ^xl 
Syr.  hemidcsmi,  ^ss. 
Aquam  ad  §iv. — M. 
A  tablespoonful  three  times  a  day.     For  a  child  five  yeai-s  old. 


FORMULA.  741 

NO.  FOEM.     PAGE. 

74.  Saline,  .        .         .         .         .         .         . 12       144 

R.  Liquor,  amm.  acet.,  ^ss. 
Spt.  sether.  nitr.,  3j 
Syr.  rosse,  ^iij 
Aquam  ad  ^iv. — M. 
A  tablespoonful  every  four  hours.     For  children  five  years  of  age. 

75.  Saline, 13      144 

R.  Amm.  carb.,  gr.  viij 

Liquor,  amm.  acet., 

Syr.  aurant.,  aa  3ss. 

Aquam  ad  ^iv. — M. 

A  tablespoonful  every  four  hours.     For  children  five  years  of  age. 

76.  Saline, 52       351 

R.  Liq.  amm.  acet.,  ^ij 
Spt.  sether.  nitr.,  3j 
Syr.  rosse,  ^iij 
Aquam  ad  3  iv.— M. 
A  tablespoonful  to  be  taken  every  four  hours. 

77.  Saline  in  acute  rheumatism, 88       665 

R.  Liq.  amm.  acet.,  ^ss. 
Acid,  salicylic,  9ij 
Syr.  aurant.,  ^iij. 
Aquam  ad  5iv. — M. 
A  dessertspoonful  every  four  hours.     For  children  six  years  of  age. 

78.  Saline  in  acute  rheumatism,     .........     89       665 

R.  Potass,  bicarb., 

Acid,  salicylic,  aa  9ij 
Syrupi,  giij 

Aquam  anethi  ad  ^iv. — M. 
A  dessertspoonful  every  four  hours.     For  children  six  years  of  age. 

79.  In  acute  rheumatism,      ..........     90       665 

R.  Sodse  salicylat.,  Qij 
Syrupi,  ^iij 
Aquam  ad  ^iv. — M. 
A  dessertspoonful  every  four  hours.     For  children  six  years  of  age. 

80.  In  incipient  phthisis,       .         .         .         .         .         .         .         .         .         .78       528 

R.  Sodse  hypophosphitis,  gss. 
Syr.  aurant.,  giij 
Inf.  calumbse  ad  ^yj. — M. 
A  tablespoonful  three  times  a  day. 


742  FORMULA. 

NO.  FOEM.     PAGE. 

81.  In  incipient  phthisis, 79       528 

R.  Sodse  hypopliospliitis,  5ss. 
Syrupi,  ^iij 

Inf.  cinch,  flav.  ad  3vj. — M. 
A  tablespoonful  to  be  taken  three  times  a  day. 


82.  In  cough  and  laryngeal  irritation,  .         .         .         .         .         .        .         .76       526 

R.  Potass,  chlorat.,  ^ss. 

Liquor,  morph.  hydrochlor.,  i^xx 
Syr.  tolutani,  ^vj 
Aquam  ad  ^ij. — M. 
5j  pro  re  nata.     For  children  from  five  to  ten  years  old. 


83.  Sedative  to  relieve  cough, .77       526 

R.  Liquor,  morph.  hydrochlor.,  '"iJJxx 
Vin.  ipecac,  5j 
Oxymellis  scillae, 
Syr.  mori.,  aa  oSS- 
Mist,  acacise  ad  ,^ij. — M. 
3j  pro  re  nata.     For  children  from  five  to  ten  years  old. 


84.  In  acute  rheumatism, 86       662 

R.  Potass,  bicarb.,  ,^ij 
Potass,  nitrat.,  ^ij 
Tinct.  opii,  "^xvj 
Syr.  limonum,  5SS. 
Aquam  ad  ^iv. — M. 
A  dessertspoonful  every  three  or  four  hours.     For  a  child  six  years  of  age. 


85.  In  acute  rheumatism,       ..........     87       665 

R.  Salicin,  ^ij 

Syr.  aurant.,  §ss. 
Aquam  cinnamomi  ad  ^iv. — M. 
A  dessertspoonful  to  be  taken  every  four  hours.     For  children  six  years  of  age. 


86.  In  sickness  and  torpid  liver,  .........     21       173 

R.  Acid,  hydrocyan.  dil.,  ^xij 
Acid  nitric,  ^xx 
Syr.  nitric,  ^ij 
Aquam  ad  .^iss. — M. 
3j  ter  der.     For  children  a  year  old. 


FORMULA.  743 

NO.  FORM.     PAGE. 

87j  In  indigestion,     ...........     19       172 

R.  Sodse  bicarb.,  gr.  xij 
Spt.  amm.  arom.,  ■";^xij 
Syr.  rliei,  vel 
Succi  taraxaci,  ^iij 
Tinct.  calnmbse,  3j 
Aqnam  anethi  ad  §iss. — M. 
^ij  ter  die.     For  cbildren  a  year  old. 

88.  In  some  forms  of  rhemnatism,         ........     91       667 

R.  Potass,  bicarb.,  ^j 
Tinct.  cinch,  co.,  ^ij 
Syr.  zingib.,  ^iij 
Aquam  ad  giv. — M. 
A  dessertspoonful  three  times  a  day.    For  children  from  eight  to  twelve  years  of  age. 

89.  In  some  forms  of  rheumatism,         ........     92       667 

R.  Potass,  bicarb.,  3;j 

Ferri  et  amm.  citr.,  gr.  xx 
Syr.  aurant.,  giij 
Aquam  cinnamomi  ad  §iv. — M. 
A  dessertspoonful  three  times  a  day.  For  children  from  eight  to  twelve  years  of  age. 

90.  Carminative  in  flatulence,      .........     43       206 

R.  Potass,  bicarb.,  gr.  viij 
01.  cajeputi,  i^viij 
Aquse  anethi,  ^j. — M. 
A  teaspoonful  three  times  a  day. 

91.  In  ophthalmia  from  small-pox,        .         .         .         .         .         ...         .17       147 

R.  Zinci  sulph.,  gr.  ij 
Vini  opii,  ii^Jxx 
Aquam  rosse,  §j — M. 
Fiat  collyrium. 

92.  In  ophthalmia  from  small-pox,         ........     18       147 

R.  Sodse  biborat.,  gr.  xij 
Zinci  sulph.,  gr.  j 
Aquse  camph.,  ,5j 
Aquam  destill.  ad^j. — M. 
Fiat  collyrium. 

93.  In  diphtheria,         ..........     55       353 

R.  Potass,  chlorat., 
Boracis,  aa  3j 
Glycerini, 
Mellis,  aa  |s.— M. 
The  throat  to  be  mopped  out  with  a  little  of  this  solution  frequently  during  the 
day,  in  diphtheria. 


744 


foe:!>iul^. 


94.  In  scarlet  fever  and  diphtheria,        .....        i 
R.  Liq.  ferri  perclilor.,  §j 
Glycerini, 
Aquae,  aa  Sss. — M. 
Fiat  solutio. — To  be  applied  to  the  throat  in  scarlet  fever  and  diphtheria 


FOEM.     PAGE 

.     10       131 


95.  In  lepra, 

96.  In  eczema, 

To  form  a  powder. 

97.  In  eczeraa, 


B.  Picis  liquidse,  vel 
Olei  rusci,  ^^ss. 
Glycerini  amyl.,  §ij. — M. 


R.  Zinci  oxid. 

Pulv.  amyli,  aa  ,5ij 

Pulv.  camphorse,  gr.  v. — M. 


R.  Pulr.  calam., 

Zinci  oxid.,  aa  oM 
Liq.  calcis,  5S3. 
Glycerini,  ^ij    - 
Aquam  rosse  ad  5VJ. — M. 


Fiat  lotio. 


99       713 


100    715 


101     715 


98.  In  congestian  of  the  liver,      ...  ......         44     233 

R.  Acid.  nit.  dil.,  5J 
Aquam  rosse  ad  gxx. 
Fiat  lotio.     Two  folds  of  linen  rag  to  be  saturated  with  a  little  of  this  lotion,  and 
applied  to  the  region  of  the  liver,  under  oil-silk. 


INDEX. 


Abdomen,  enlargement  of,  298 
Abscess  in  the  ear,  715 
Acid,  phosphoric,  in  phthisis,  528 
Aconite  in  scarlet  fever,  129 

in  congestion  of  brain,  621 
'  in  pneumonia,  460 

in  tonsillitis,  158 
Adenoid  tissue,  473 
Air,  importance  of,  44 
Alcohol  in  acute  disease,  56 
Albuminuria  in  scarlet  fever,  134 

in  diphtheria,  338 

in  intermittent  fever,  253 
Almond  cakes  in  diabetes,  291 
Alopecia  areata  (see  Tinea  decal vans),  727 
Alum,  379 
Ammonia,  carbonate  of,  426 

in  bronchopneumonia,  464 
Amyloid,  or  lardaceous  disease  of  liver,  239 

of  kidney,  269 
Ansemia,  697 

idiopathic,  or  pernicious,  702 

treatment,  699 

varieties  of:  1.  Acute;  2.  Chronic,  699 
Anasarca  in  chronic  Bright's  disease,  treat- 
ment of,  273 

drainage-tubes  in,  273 
Anorexia,  169 
Antimony,  48 

in  asthma,  402 

in  bronchitis,  422 

in  chorea,  637 

in  croup,  333 

in  meningitis,  567 

in  pneumonia,  459 

in  tonsillitis,  158 
Aortic  valves,  disease,  545 

regurgitation,  546 

stenosis,  545 
Aperients,  ill  effects  of,  46 
Aphthfe,  148 
Apoplexy,  622 
Arsenic  in  chorea,  635 

in  chronic  urticaria,  720 

in  eczema,  724 

in  psoriasis,  721 
Arterial  murmurs,  694 
Ascarides,  302 

injections  of  iron  and  quassia  in,  303 


Ascaris  lumbricoides,  305 

santonin  in,  306 
Ascites,  299 

copaiba  in,  301 

digitalis  in,  301 

pai'acentesis  in,  301 
Asphyxia,  diseases  terminating  in,  55 
Asthma,  393 

causes  of,  393 

diagnosis,  397 

pathology,  399 

treatment,  401 
Atropia,  sulphate  of,  377 

in  phthisis,  525 

in  whooping-cough,  377 
Atrophy,  73 

causes  of,  73 

of  liver,  235 
Aura  epileptica,  589 
Aural  polypi,  711 

Backwardness,  616 
Basilar  meningitis,  577 
Bathing,  cold,  45 
Baths,  cold,  in  fever,  130 

in  diarrhcea,  181 

warm,  in  nephritis,  262 
Bael,  extract  of,  ifl  diarrhcea,  193 
Belladonna  in  asthma,  401 

in  enuresis,  284 

in  laryngismus  stridulus,  365 

in  phthisis,  524 

in  rickets,  681 

in  scarlet  fever,  136 

in  whooping-cough,  376,  382 
Bilious  diarrhoea,  177 
Bismuth  in  diarrhcea,  191 
Blood  in  ansemia,  692 

in  rheumatism,  567 

murmurs,  diagnosis  of,  696 
Boils  as  a  result  of  small-pox,  145 
'Borax  in  stomatitis,  150 
Bran-cakes  in  diabetes,  291 
Brain,  diseases  of,  557 
Breathing,  harshness  of,  513 
Bromide  of  potassium  in  asthma,  401 

in  epilepsy,  601 

in  laryngismus  stridulus,  365 

in  meningitis,  568 


746 


INDEX. 


Bromide  of  potassium  in  wliooping-cough, 

378 
Bronchial  glands,  enlargement  of,  384 

in  tuberculosis,  478 

in  whooping-cough,  372 

respiration,  518 
Bronchitis,  acute,  413 

symptoms  of,  414 

chronic,  419 

kettles,  320 

pathology,  421 

temperature  of  room  in,  424 

treatment,  422 
Bronchopneumonia  (see   Catarrhal  pneu- 
monia), 461 
Bronchophony  in  phthisis,  515 
Bronchorrhoea,  427 
Bruit  de  cuir,  534 
Bruit  de  diable,  696 
Bruit  de  frotteraent,  534 
Bruit  de  soufflet  in  ansemia,  695 

in  mitral  disease,  548 
Bulimia,  169 
Bullock's  acid  glycerin  of  pepsin,  76 

Cajeput  oil,  206 
Calomel  in  jaundice,  235 

in  pleurisy,  435 
Calumba,  172 
Cancer  of  the  kidney,  278 
Cancrura  oris,  153 
Cannabis  Indica,  377 

Carbolic  acid,  inhalation  of,  in  whooping- 
cough,  382 

in  phthisis  (see  Spray  inhalation),  525 
Carbonate  of  potash  in  whooping-cough, 

380 
Cardiac  murmurs,  694 
Carpo-pedal  contractions,  605 
Castor  oil  paste,  46 

in  diarrhoea,  185 

in  dysentery,  199 
Catarrhal  deafness,  709 

phthisis,  506 

pneumonia,  461 
Catechu,  192 

Cavernous  respiration,  518 
Cephalalgia  epileptiformis,  587 
Cerebral  hemorrhage  (see  Apoplexy),  622 
Cerebro-spinal  meningitis,  643 
Chilblains,  718 

treatment,  719 

varieties  of,  719 
Chloral  hydrate,  378 

in  asthma,  402 

in  Ijronchitis,  424 
Chloralum,  136 

Ciilorate  ofyjotash  in  stomatitis,  154 
Chlorine  drink,  187,  352 
Cholera  infantum,  177 
Chorea,  024 

arsenic  in,  635 


Chorea,  causes  of,  628 

curara  in,  632 

hydrate  of  chloral  in,  633 

iron  in,  635 

pathology,  630 

strychnia  in,  635 

succus  conii  in,  632 

sulphate  of  zinc  in,  636 

treatment,  631 
Chronic  phthisis,  507  ■ 
Chylification,  105 
Chymification,  165 
Cirrhosis  of  kidney,  265 

of  liver,  227    ' 

of  lungs,  508 
Cochineal,  380 
Cod-liver  oil  in  atrophy,  76 

in  chronic  bronchitis,  427 

in  phthisis,  521 

in  rickets,  682 
Coffee  in  asthma,  402 
Colic,  205 

treatment  of,  206 
Collapse,  causes  of,  55 

in  diarrhoea,  188 
Condy's  fiijid,  136 
Congestion  of  the  brain,  618 

causes  and  symptoms,  619 

treatment,  621 
Constipation,  200 

treatment  of,  202 

in  meningitis,  571 
Convulsions,  004 

in  dentition,  69 

in  fever,  87 

in  pneumonia,  455 
Copaiba,  301 
Copper,  sulphate  of,  in  chorea,  636 

in  diarrhoea,  1 93 
Corrigan's  pulse,  545        » 
Coryza,  310 
Cough  in  heart  disease,  553 

in  phthisis,  525 
Counter-irritation  in  pericarditis,  537 
Cow-pox,  97 

Cranio-tabes  (see  Rickets),  678 
Cretinism,  015 
Croton-chloral,  377 
Croup,  diagnosis  from  diplitheria,  327 

from  laryngismus  stridulus,  232 

tracheotomy  in,  334 

treatment,  332 

varieties  of,  322 
Croupous  pneumonia,  451 

diagnosis  of,  457 

(see  Pneumonia),  448 
Cupping  in  acute  nephritis,  261 
Cyanosis,  555 
Cynanche  parotidea  (see  Mumjis),  163 

tonsillitis  (see  Tonsillitis),  157 

trachealis  (see  Croup),  322 
Cystitis,  acute,  286 


INDEX. 


747 


Debility,  causes  of,  62 

definition  of,  63 

treatment,  67 
Defecation,  165 
Delirium  in  pericarditis,  534 

in  pneumonia,  455 
Dentition,  first  and  second,  68 

treatment  of,  70 

use  of  gum  lancet  in,  72^ 
Desquamation  in  scarlet  fever,  117 
Diabetes  insipidus,  292 

pathology  and  treatment,  293 

mellitus,  287 

pathology  of,  290 

skim-milk  in,  291 

tests  for  sugar  in,  289 
Diaphoretics  in  nephritis,  261 
Diarrhoea,  174 

bilious,  177 

choleraic,  177 

chronic,  182 

dysenteric,  182 

in  dentition,  70 

in  fever,  85 

in  phthisis,  527 

in  small-pox,  146 

lienteric,  181 

muco-enteritis,  179 

simple,  176 

treatment,  183 

varieties  of,  176 
Digestive  ferments,  76 
Digestion  of  starch,  of   sugar,  at  time  of 

weaning,  167 
Digitalis  in  ascites,  301 

in  chronic  Bright's  disease,  273 

in  epilepsy,  604 

in  heart  disease,  552 

in  nephritis,  262 

in  pleurisy,  438 
Dilatation  and  hypertrophy  of  heart,  553 

signs  of,  554 
Dinneford's  solution  of  magnesia,  46 
Diphtheria,  336 

albuminuria  in,  338 

causes  of,  341 

diagnosis  from  croup,  326 

diphtheritic  paralysis,  343 

morbid  anatomy  of,  346 

period  of  incubation,  337 

sequelfe,  343 

tracheotomy  in,  354 

treatment,  350 
Disease,  acute  and  chronic,  51 
Drainage-tubes  in  anasarca,  273 

in  hydropericardium,  540 

in  pleuritic  effusion,  445 
Dry  crackling  rhonchus,  516 
Dropsy  after  scarlet  fever,  treatment  of, 
133-255 

of  the  kidney  (see  Hydronephrosis), 
280 


Duchenne's  paralysis,  655 

pathology  and  treatment,  657,  658 
Dura  arachnitis  (pachymeningitis),  559 
Dysentery,  198 
Dyspepsia,  169 
Dyspnoea  in  pleurisy,  428 

in  pneumonia,  4-57 
Dysuria,  274 

Ear,  diseases  of,  708 

Ecthyma,  725 

Eczema,  acute  and  chronic,  722 

of  the  ear,  714 

treatment,  724 
Emetics,  danger  of,  in  head  affections,  in 
peritonitis,  and  in  great  debility,  49 

in  bronchitis,  423 

in  some  acute  diseases,  57 

safe  in  croup,  whooping-cough,  bron- 
chitis, pneumonia,  and    tonsillitis, 
49 
Emphysema,  occasional  coexistence  with 
tuberculosis,  409 

treatment,  411 

two  varieties:    1.  Vesicular;    2.  In- 
terlobular, 405 
Empyema,  445 
Endocarditis,  540 

treatment,  541 

ulcerative,  542 
Enemata,  nutritive,  77 

starch,  90 
Entero-colitis  (see  Muco-enteritis),  179 
Enuresis,  282 

belladonna  in,  284 

faradization  in,  285 
Epilepsy,  585 

causes  of,  592 

diagnosis,  595 

diet  in,  599 

morbid  anatomy  of,  594 

prognosis  and  treatment,  598 

symptoms  of,  586 

two  varieties  :  1 .  Le  grand  mal ;     2, 
Le  petit  mal,  585 
Epileptiform  seizures,  596 
Epistaxis,  316 

in  diseases  of  spleen,  246 

in  typhoid  fever,  88 

plugging  nares  in,  317 
Ergot  in  epilepsy,  603 

in  hsemoptysi^,  526 
Ergotin,  subcutaneous  injection  of,  653 
Eruption,  character  of,  in  measles,  103 

in  chicken-pox,  100 

in  scarlet  fever,  116 

in  typhoid  fever,  85 

in  variola,  138 

Kotheln,  112 
Eruptive  fevers,  97 

Erythema,  varieties   of:    1.   Simplex;  2. 
Nodosum.     3.  Intertrigo,  717 


748 


I^'DEX. 


Ethyl,  iodide  of,  403 
Exercise,  importance  of,  44 

Faradization  in  chorea,  637 

in  enuresis,  285 
Fatty  liver,  241 
Febris  ephemera,  82 
Fehling's  solution,  289 
I-ermentation  test,  289 
Fever,  intestinal,  83 

scarlet.  116 

typhoid,  84 
Fevers  of  childhood,  78 
Fibroid  phthisis,  508 
Food,  in  diarrhcBa,  190 

iasufficiency  of,  58 

predenlal  period,  165 
Fremissement  cataire,  548 
Frog  belly,  674 

Gallic  acid  in  diarrhoea.  191 

in  hsematemesis,  277 

in  hsemoptysis,  526 

in  sweating  of  phthisis,  524 
Galloping  consumption,  504 
Gangrene  of  mouth,  154 
Gastritis,  194 
German  measles.  111 
Giant  cells,  473 
Gingivitis,  156 
Glands,  caseous  degeneration  of,  390 

enlarged  bronchial  and  mediastinal, 
383 

enlarged  cervical,  702 

mesenteric,  in  fever,  85' 
Gluten  bread  in  diabetes,  291 
Glvcosuria,  288 
Gout,  668 

Granular  kidney,  276 
Growth  of  children.  20 
Guaiacum  in  tonsillitis,  159 
Gurgling  rhonchus,  517 

Hgematemesis,  196 
Hematuria,  277 
Haemoptysis,  511 

iron,  gallic  acid,  acetate  of  lead,  ergot 
in,  526 
Haemorrhage,  causes  of,  55 

in  fever,  96 
Headache  in  meningitis,  573 

in  scarlet  fever,  127 
Heart  cough,  553 
Heart,  diseases  of,  529 

functional,  530 

neurosal  affections  of,  531 

organic,  532 

valvular  diseases  of,  544 
Hemichorea,  627 
Hemiplegia  in  meningitis,  574 
Herpes  two  varieties:  1.  Herpes  labialis; 
2.  Herpes  zoster,  725 


Honey,  as  a  laxative,  46 
Hiunid  crackling  rhonchus,  516 
Hydatids  of  liver,  237 

diagnosis,  238 

treatment,  239 
Hyd.  c.  Creta  in  cirrhosis,  229 

in  jaundice,  233 
Hydrobromic  acid,  383 
Hydrocephalus,  chronic,  579 

compression-puncture,  584 

iodide  of  potassium  in,  583 

symptoms,  581 

treatment,  582 
Hydrocyanic  acid,  379 
Hydronephrosis,  375 
Hydropericardium,  539         ^ 
Hyoscyamus  in  epilepsy,  604 
Hyperpyrexia  in  rheumatism,  666 
Hypertrophy  and  dilatation  of  heart,  553 
Hypophosphites    of   lime    and    soda    in 
phthisis,  522 

■with  cod-liver  oil,  528 

Icterus,  231 

neonatorum,  233 

treatment  of,  233 
Idiocy,  615 

Ileum,  glands  of,  in  fever,  85 
Imbecility.  617 
Impetigo,  726 

Incontinence  of  urine  (see  Enuresis),  282 
Incubation-period,  diphtheria,  336 

measles,  101 

scarlet  fever,  116 

small-pox,  138 

whooping-cough,  377 
Indigestion,  164 

causes  of,  170 

treatment  of,  172 
Infantile  convulsions,  604 

causes,  606 

symptoms,  605 

terminations,  610 

treatment,  611  . 

Infantile  paralysis,  647 

pathology,  651 

symptoms,  649 

treatment,  653 
Infantile  remittent  fever,  83 
Infection  in  fever,  134 
Inhalation,  chloroform,  365 

carbolic,  381,  525 

in  asthma,  402 

in  pneumonia,  463 

of  ethyl,  403,  411 
Inhalations,  in  acute  disease,  57 
Insalivation,  166 
Intestinal  fever  (see  Typhoid  fever),  83 

obstruction,  207 

worms,  302 
Intussusception,  two  forms,  211 
Invagination,  211 


INDEX. 


749 


Invagination,  diagnosis,  220 

medical  and  mechanical,  222 
Iodine,  applicatian  of,   in  enlarged  bron- 
chial glands,  392 
injections  of,  in  chronic  pleurisy,  439 
in  pleuritic  effusion,  447 
Ipecacuanha,  in  asthma,  402 
in  diarrhoea,  191 
in  pneumonia,  464 
Iron,  preparations  of,  47 

syrup  of  the  hypophosphite,  Parrish's 
chemical  food,  Vinum  ferri,  Ferrum 
redactum,  Troch.  ferri  redacti,  47, 
48  _     ^ 

in  chronic  Bright's  disease,  271 
in  scarlet  fever,  133 
tincture  of  the  perchloride  in  haemop- 
tysis, 526 

Jacket-poultice  in  pneumonia,  460 
Jalap,  compound  powder  of,  in  nephritis, 

261 
Jaundice  (see  Icterus),  231 

Keratitis,  in  syphilis,  688 
Kidneys,  cancer  of,  277 

cirrhosis  of  kidney,  267 

congestion,  252 

diseases  of,  248 

granular  kidnev,  cirrhosis  of  kidney, 
267 

large  white  kidney,  265 

waxv  kidney,  269 
Kousso,  309 
Krameria  in  diarrhoea,  193 

in  dysentery,  199 

Lactic  acid,  in  the  blood  in  rheumatism, 

660 
Laryngeal  and  tracheal  irritation,  317 
Laryngismus  stridulus,  357 

association  with  rickets,  680 

nature  of,  360 

pathology,  363 

treatment,  364 
Laryngo-tracheal  diphtheria,  322 
Lead,  acetate  of,  in  diarrhoea,  191 

in  phthisis,  526 
Leeches,  in  meningitis,  567 

in  pericarditis,  537 
Lepra  (see  Psoriasis),  721 
Lepto-meningitis  (see  Meningitis),  557 
Leucocythemia,  706 
Lichen,  720 

urticatus,  720 
Lime,  hvpophosphite  of,  in  phthisis,  522, 

527 
Liquor  pepticus,  76 

pancreaticus,  76 
Liquorice-powder,  compound,  203 
Lithiasis,  274 


Liver,    adhesive    inflammation    of    (cir- 
rhosis), 228 

albuminoid  enlargement  of,  230 

congestion  of,  225 

diseases  of,  225 

hydatids  of,  237 

scrofulous  enlargement  of,  240 

syphilitic  disease  of,  229 
Lobar  pneumonia   (see    Croupous    pneu- 
monia), 451 
Lobular  pneumonia   (see   Catarrhal  pneu- 
monia), 461 
Logwood,  191 
Lung,  collapse  of,  420 
Lupus  vulgaris,  726 
Lymphadenoma,  704 


Male  fern  in  tapeworm,  309 
Malt  extract  in  phthisis,  525 
Manna,  202 

Marasmus  (see  Atrophy),  73 
Masturbation  a  cause  of  chorea,  629 

of  epilepsy,  601,  629 
Measles  (see  Morbilli),  102 
Mediastinal  glands    (see   Enlarged  bron- 
chial glands),  383 
Melffina,  197 
Melancholia,  614 
Meningitis,  simple,  557 

causes,  559 

symptoms,  563 

treatment,  566 

tubercular,  568 

symptoms  of,  570 

treatment,  577 

basilar,  577 
Mental  disorder,  614 
Mercurial  salivation,  155 
Metallic  tinkling,  519 
Meteorism,  205 
Milk,  composition  of,  26 

condensed,  29 

constituents  of,  31 

evil  consequences  of  impure,  38 

in  nephritis,  261 

in  woman,  ass,  cow,  goat,  27 

microscopic  examination  of,  28 

utility  of,  in  disease,  34 

wet-nurses,  38 
Mitral  regurgitation,  548 

stenosis,  549 
Moore's  test,  289 
Morbilli,  causes  of,  105 

complications  of,  103 

sequelse,  108 

three  varieties  of,  102 

treatment  of,  109 
Mouth  and  fauces,  diseases  of,  148 
Muco-enteritis,  179 

Mumps  (see  Cynanche  parotidea),  162 
Myelitis,  641 


750 


INDEX. 


Myelitis,  treatment  of,  642 
Myocarditis,  542 

Nasal  cavities,  diseases  of,  310 
Nephritis,  acute  desquamative,  254 

chronic  desquamative,  264 

pathology  of— morbid  anatomy,  256 

treatment  of,  261 
Nervous  and  hysterical  symptoms,  614 
Nettlerash  (see  Urticaria),  719 
Neuralgia,  658 
Night  terrors,  612 

causes,  diagnosis,  and  treatment,  613 
Nitrate  of  silver  in  dysentery,  199 

topical  application  of,  in  whooping- 
cough,  380 
Nitric  acid  in  whooping-cough,  379 
Nux  vomica  in  asthma,  403 

Obstetrical  paralysis  (see  Infantile  paraly- 
sis), 647 
OEdema  of  lungs,  470 

diagnosis  from  pneumonia,  457 
Oil  of  male  fern,  308 
Ophthalmia  in  small-pox,  147 
Opium  in  dysentery,  200 

in  intestinal  obstruction,  210 

in  intussusception,  222 

in  peritonitis,  296 
Ophthalmoscopic  signs  in  intracranial  dis- 
ease, 579 
Optic  neuritis,  565 
Orthopno3a  in  pericarditis,  535 
Otorrhoea,  710 
Oxaluria,  277 

Oxyuris  vermicularis  (see  Ascarides),  302 
Ozsena,    varieties   of:    1,      Scrofulous;    2. 
Syphilitic;  3.  Traumatic;  4.  Idio- 
pathic, 314 

treatment,  315 

Palpitation,  causes  and  treatment  of,  530 
Pancieatin,  76 
Paracentesis  in  ascites,  301 

in  pleurisy,  443 
Paralysis  from  brain  disease,  647 

in  meningitis,  574 
Pectoriloquy,  519 

Pediculi  corporis  (see  Phthiriasis),  728 
Pepsin,  70 
Peptonized  gruel,  77 

milk,  77 
Percussion,  dulness  in  phthisis,  514 

wooden,  515 
Pericarditis,  diagnosis  and  prognosis,  536 

})!orbid  anatomy  of,  536 

treatment,  537 

two  varieties  of: 

1.  Acute,  532 

2.  Clironic,  538 
Peritonitis,  acute,  294 

chronic,  296 


Peritonitis,  diagnosis  from  colic,  296 
Perityphlitis  (see  Tj'phlitis),  299 
Petit  mal,  590 
Pertussis,  366 

inculDation  period,  368 

treatment,  373 
Peyer's  patches  in  typhoid  fever,  89 
Pharyngitis,  simple,  160 
Phosphorus  in  chorea,  030 

in  epilepsy,  603 
Phthiriasis,  728 
Phtliisical  laryngitis,  519 
Phthisis,  500 

acute  forms  of,  503,  504 

bronchophony,  515 

catarrhal,  506 

chronic,  507 

diagnosis  and  treatment,  520 

dulness  on  percussion,  514 

harshness  of  breathing,  513 

physical  signs  of,  512 

vocal  fremitus,  514 
Pia  arachnitis,  558 
Pigeon  breast,  159 
Pilocarpin  in  asthma,  404 
Pitting  in  small-pox,  146 
Pleurisy,  acute,  427 

causes,  431 

diagnosis  and  prognosis,  432 

d3'spnoea  in,  428 

physical  signs  of,  429 

treatment  of,  434 

chronic,  437 
Pneumonia,  448 

three  stages  of,  429 
croupous,  451 
apex,  455 

pathology,  456 
treatment,  458 
broncho,  461 

23athology  and  treatment,  463 

chronic  lobular,  466 
Potash,  acetate  of,  in  pleurisy,  439 
Potassium,  iodide   of,   in   chronic  hydro- 
cephalus, 583 

in  meningitis,  579 

in  syphilis,  690 

bromide.     See  Bromide  of  potassium. 
Pot-belly,  298 
Poultices,  value  of,  in  the  lung  diseases  of 

children,  460 
Prepuce,  removal  of,  in  enuresis,  285 
Prolapsus  ani,  193 

Prune-juice  color  sputa  in  pneumooia,  456 
Psoi-iasis,  721 
Pulmonary  stenosis,  556 
Pulse  in  aortic  regurgitation,  546 

in  aortic  stenosis,  545 

in  cyanosis,  555 

in  mitral  regurgitation,  548 

in  mitral  stenosis,  550 

in  pericarditis,  534 


INDEX. 


751 


Pulse  in  pneumonia,  450,  453 

in  tuberculosis,  494 
Purgatives  in  acute  disease,  57 
Pyrosis,  170 
Pythogenic  fever  (see  Typhoid  fever),  83 

Quassia,  303 

Quinine  in  diphtheria,  352 

in  fever,  83 

in  tuberculosis,  523 
Quinsy  (see  Tonsillitis),  157 

Kaw-meat  juice,  76,  109,  190 
Regurgitation,  aortic  and  tricuspid,  546 

mitral,  548 
Remittent  fever  (see  Typhoid  fever),  83 
Renal   concretions   and   calculi   (see  Dy- 

suria),  274 
Respiration,  in  meningitis,  573 

in  phthisis,  514 

in  tuberculosis,  494 
Retropharyngeal    abscess,   diagnosis    and 

treatment,  162 
Rhubarb,  svrup  of,  46 
Rickets,  669 

cod-liver  oil  in,  682  *' 

diagnosis  from  hydrocephalus,  678 

morbid  anatomy,  679 

treatment,  680 
Rigors  in  pneumonia,  450 
Rheumatism,  acute,  658 

cold  bath  in,  666 

pathology,  660 

treatment,  661 
Rhonchus,  dry  crackling  in  phthisis,  515 

gurgling,  517 

humid  crackling,  516 

subcrepitant,  516 
Roseola,  720 
Roses,  syrup  of,  46 
Rotheln,  or  German  measles.  111 

diagnosis  and  treatment,  114' 
Round  worm   (see  Ascaris  lumbricoides), 
304 

Salicin,  664 

Salicylate  of  soda,  665 

Salicvlic  acid,  664 

Santonin,  306 

Scabies,  727 

Scalp,  cli'ieases  of,  727 

Scarlet  fever,  causes  of,  125 

mortality,  125 

pathology  of,  122 

precautionary  measures  in,  135 

sequelte,  127 

symptoms  of  latent,  121 

three  varieties  of,  116 

treatment,  128 
Sedatives,  caution  in  the  use  of,  49,  525 
Senega,  463 


Senna,  aromatic  syrup  of,  46 

Sexual  precocity,  664 

Shower-baths  in  chorea,  637 

Silver,  nitrate  of,  199 

Simple  febricula,  80 

Skin,  diseases  of,  716 

Small-pox  (see  Variola),  137 

Snuffles  in  syphilis,  685 

Soda,  hypopJiosphite,  in  chorea,  636 

in  phthisis,  522,  527 
Spinal  chord,  diseases  of,  637 

hfemorrhage,  638  \ 

ii-ritation,  638 

from  masturbation,  638 

meningitis,  640 
Spleen,  diseases  of,  242 

diagnosis  of,  246 

epistaxis  in,  246 

in  fever,  84 

syphilitic  disease  of,  247 
Spray  inhalation,  in  asthma,  404 

in  diphtheria,  353 

in  scarlet  fever,  132 
Squill,  439 

Squinting  in  meningitis,  574 
Starch,  digestion  of,  167 
Status  epilepticus,  586 
Steam-draft  inhaler,  131 
Stenosis,  aortic,  545 

mitral,  549 

pulmonary,  556    , 
Stimulants,  in  diarrhoea,  187 

in  measles,  110 

in  scarlet  fever,  134 

in  small-pox,  146 

in  typhoid  fever,  91 

unnecessary  for  healthy  children,  91 
Stomatitis  follicularis,  149 

fungosa,  150 

gangrenous,  154 

simplex,  148 

ulcero-membranous,  152 
Stone  in  the  kidney,  symptoms  of,  275 

in  bladder,  276 
Stramonium  in  asthma,  401 
Stomach,  softening  of,  196 
of  intestines,  197 
vStrychnia  in  chorea,  635 

in  emphysema,  411 

in  phthisis,  521 
St.  Vitus's  dance  (see  Chorea),  624 
Sugar,  digestion  of,  167 

in  the  urine,  tests  for,  289 
Sweating  in  phthisis,  524 
Syphilis,  684 

diagnosis  and  treatment,  689 

mercurial  inunction  in,  690 

mercurv  and  iodide  of  potassium  in, 
690  _ 

spleen  in,  687 
Syncope,  531 
Syringomyelus,  642 


752 


INDEX. 


Tabes  mesenterica,  297 

diagnosis  and  ireatnaent,  298 
Taraxacum,  172 
Tapeworm,  307 

kousso  in,  307 

oil  of  male  fern  in,  307 
Teeth,  temporaiy  and  permanent — symp- 
toms of  first  dentition,  68 
convulsions  in,  69 
diarrlicea  in,  69,  186 
Threadworms  (see  Ascarides),  302 
Thrush  (see  Aphtha;),  150 
Tinea  decalvans,  717 

tonsurans,  717 
Tobacco  in  asthma,  402 
Tonsillitis,  157 

aconite  in,  158 

antimony  in,  158 

treatment  of,  158 
Tonsils,  hypertrophy  of,  159 
Tracheotomy  in  croup,  333 

in  diphtheria,  354 
Tracheitis  (see  Croup),  331 
Treacle  as  a  laxative,  46 
Trichocephalus  dispar,  307 
Tricuspid  regurgitation,  546 
Trommer's  test,  289 
Tubercle  of  the  kidney,  278 
Tubercular  meningitis,  568 

phthisis,  507 
Tubercle,  gray  and  yellow,  476 

miliary,  478 
Tuberculosis,  472 

causes  of,  481 

pulse  in,  493 

respiration  in,  495 

sweating  in,  64 

symptoms  of,  488 

temperature  in,  489 

treatment,  520 
Tumors,  abdominal,  237,  243,  277,  279 
Tympanitis  in  typhoid  fever,  87 
Typhilitis,  206 

diagnosis  from  intussusception,  221 
Typhoid  fever,  83 

diagnosis  from  meningitis,  92 
from  tuberculosis,  94 

sequelae,  morbid  appearances  of,  89 

symptoms  of,  85 

treatment  of,  92 


Ulcerative  endocarditis,  542 
Uraemia  in  scarlet  fever,  127 
Uric  acid  gravel,  treatment  of,  276 
Urinary  sediments,  composition  of,  276 
Urine,   deficiency   of  chlorides   in   pneu- 
monia, 454 

in  chorea,  627 

in  infantile  paralysis,  651 

in  rickets,  675 

specific  gravity  of,  251 
Urticaria,  719 

Vaccinia  or  vaccination,  97 
Vaginal  discharges,  691 
Valves,  aortic  disease  of,  545 
Valvular  disease  of  heart,  544 

treatment  of,  552 
Vapor-bath  in  acute  nephritis,  262 
Varicella,    diagnosis    and    treatment    of, 

100 
Variola,  or  small-pox,  cnuses  of,  143 

morbid  appearances,  126 

mortality  of,  143 

ophthalmia,  147 

prevention  of  pitting,  146 

prognosis,  143 

sequelae,  145 

three  varieties  of,  138 

treatment,  144 

varioloid,  or  modified,  141 
Venesection  in   congestion  of  the   brain, 

_    620  _ 

in  pericarditis,  537 

in  pneumonia,  458 
Venous  murmurs,  694 
Vinum  antimonialis,  423 
Vitiated  appetite,  169 
Vomiting  in  diarrhoea,  188 

in  indigestion,  1<38 

in  meningitis,  571 

in  pneumonia,  454 

Waxy  kidney,  269 

Weaning,  state  of  digestion  in,  167 

Whooping-cough  (see  Pertussis),  366 

Zinc,  bromide  and  oxide  of,  in  epilepsy, 
603 
sulphate  of,  in  chorea,  636 

in  whooping-cough,  376,  382 


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RECENT  PUBLICA  TIONS. 


BIBLE  HYGIENE;   or,  Health   Hints, 

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General,  Fever,  and  Convalescent :  their  Progress,  Management,  and  Work. 
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With  an   Appendix   containing  much    statistical  and 
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A  MANUAL  OF  THE  DISEASES  OF  CHILDREN. 

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RECENT  PUBLICA  TIONS. 


5 


A  MANUAL  OF  OPHTHALMOSCOPY,  for  the  Use  of  Students. 

By    Dr.    Daguenet.      Translated    by    C.    S.   Jeaffreson,   Surgeon   to   the 
Newcastle-on-Tyne  Eye  Infirmary.    With  Engravings.     i8mo.     Price  $1.50. 


Part  i. — i.  Optical  Considerations.  2.  Ophthalmo- 
scopy. 3.  Different  kinds  of  Ophthalmo- 
scopes. 4.  Rules  to  be  followed  in  the 
Manipulation  of  the  Ophthalmoscope. 

Part  2. — i.  Functional  Examination  of  the  Eye. 
2.  Diagnosis  of  Visual  Disturbances. 

Part  3. — Affections  of  Deeper  Structures  of  the  Eye. 


Optic  Nerve  and  Retina.  2.  Affections  of  the 
Optic-  Nerve.  3.  Affections  of  the  Retina. 
4.  Choroid  (Ophthalmoscopic  Appearances) — 
Affections  of  the  Choroid.  5.  Affections  of  the 
Vitreous  Body.  6.  Amblyopia  and  Amaurosis, 
properly  so  called.  7.  Ophthalmoscopic  Diag- 
nosis of  Errors  of  Refraction. 


The  Author's  object  has  been  to  condense,  in  as  small  a  number  of  pages  as 
possible,  all  that  it  is  necessary  to  know,  to  study  with  benefit  diseases  of  the 
eye,  bringing  into  prominence  the  value  oi  functional  symptoms  ;  for  they  often 
constitute  excellent  guides,  which  are  too  frequently  neglected  or  misunderstood. 

The   Translator   says :    "It  seems   to  fill  a  gap  existing  in   the  elementary  - 
literature  of  the  ophthalmoscope.     Its  portable  size,  the  condensed  nature  of  its 
text,    and   the   admirably   systematic   arrangement   of  its   contents,    render   it 
extremely  useful  as  a  manual  for  students." 

WHAT  EVERY  MOTHER  OUGHT  TO  KNOW. 

By  Edward  Ellis,  m.d..  Author  of  a  Practical  Manual  on  the  Diseases  of 
Children.     i6mo.     Cloth.     Price  75  cts. 


BY   the   same   author. 

A  PRACTICAL  MANUAL  OF  THE  DISEASES  OF  CHILDREN.     With  a  Formulary. 

Edition.     Crov/n  8vo.     In  the  Press. 


Fourth 


"The  reader  will  find  in  thiswork  a  large  amount  of 
valuable  and  practical  information.  The  author  has  a 
faculty  of  sketching  out  the  characteristics  of  disease 
and  their  treatment  in  striking  outlines,  and  of  making 


his  points  very  clear  and  impressive.  We  have  perused 
it  with  much  satisfaction,  and  commend  it  to  the  atten- 
tion of  practitioners  generally  as  a  work  of  singular 
excellence." — N.  Y.  Medical  Record. 


BRIGHT'S    DISEASE.     How   Persons  Threatened  or  Afflicted 
with  this  Disease  Ought  to  Live. 

By  Joseph  F.  Edwards,  m.d.     i6mo.     Cloth.     Price  75  cents. 

The  author  gives,  in  a  readable  manner,  those  instructions  in  relation  to 
Hygiene,  Clothing,  Eating,  Bathing,  etc.,  etc.,  which,  when  carried  out,  will 
prolong  the  life  of  those  suffering  from  this  disease,  and  a  neglect  of  which 
costs  annually  many  lives. 

"A  clear  statement  of  some  of  the  rules  of  life,  which 
will  insure  the  longest  lease  of  life,  and  the  greatest 
measure  of  health." — Providence  Press. 


"  Every  one  should  read  this  excellent  little  volume, 
in  which  Dn  Edwards  describes  and  defines  the 
disease." — Providence  yournal. 

"  This  little  book  is  prepared,  not  in  the  interest  of 
the  doctor,  but  of  the  sufferer." — Louisville  Christian 
Observer. 

"What  should  be  done  and  avoided  are  clearly 
shown,  and  the  information  communicated  is  of  general 
interest." — Albany  yournal. 

"A  remarkably  able  and  useful  treatise  upon  an 
obscure  and  vital  subject." — North  Anierica^i. 

"  It  encourages  the  sufferer  as  well  as  instructs  him." 
—  Vongregationalist . 


"  Will  be  eagerly  welcomed  by  thousands  of  people. 
The  malady  is  one  of  a  peculiarly  insidious  character, 
and  it  may  be  asserted  with  confidence  that  this  book 
will  be  a  very  valuable  one  for  medical  men  as  well  as 
laymen.  The  book  is  written  in  good,  plain  English, 
and  with  clearness." — Stoddart's  Review. 

"  Physicians,  as  well  as  laymen,  will  find  the  work 
interesting,  and  will  obtain  many  valuable  hints  as  to 
the  proper  hygiene  to  be  observed  in  this  disease." — 
Medical  News,  Cincinnati. 


BY   THE   SAME   AUTHOR.       {Just  Ready.'] 

CONSTIPATION.     Plainly   Treated   and    Relieved  without  the 
Use  of  Drugs. 

By  Joseph  F.  Edwards,  m.d.     i6mo.     Cloth.    Price  75  cents. 


PRESLE V  BLA KIS TON'S. 


DIAGRAMS   OF   THE    NERVES   OF   THE    HUMAN  BODY, 

Exhibiting  their  Origin,  Divisions,  and  Connections,  with  their  Distribution  to 
the  various  Regions  of  the  Cutaneous  Surface,  and  to  all  the  Muscles.  By  Wil- 
liam H.  Flower,  f.r.c.s.,  f.r.s.,  Hunterian  Professor  of  Comparative  Anato- 
my, and  Conservator  of  the  Museum  of  the  Royal  College  of  Surgeons.  Third 
Edition,  thoroughly  revised.  With  six  Large  Folio  Maps,  or  Diagrams.  Royal 
Quarto.     Price  ^3.50. 

"The  nerves  and  ganglia  are  clearly  represented. 
The  impressions  are  well  made,  and  no  doubt  the 
diagrams  will  prove  useful." — Medical  and  Surgical 


"Admirably  arranged,  and  will  be  of  incalculable 
aid  to  the  student  of  anatomy.  Each  of  the  large  and 
beautiful  plates  is  accompanied  with  explanatory  text." 
—N.  Y.  Medical  Record. 


Reporter. 


POTABLE  WATER. 

How  to  form  a  Judgment  on  the  Suitableness  of  Water  for  Drinking  Purposes. 
Addressed  to  Medical  Officers  of  Health  and  Sanitary  Authorities.  By  Chas. 
Ekin,  f.c.s.    Second  Edition  Revised.     Crown  8vo.     75  cents. 

WATER  ANALYSIS    For  Sanitary  Purposes,   With    Hints   for 
the  Interpretation  of  Results. 

By  E.  Frankland,  ph.d.,  d.c.l.  With  Illustrations,  Tables,  etc.,  etc.  i2mo. 
Cloth,     gi.oo. 

"The  name  of  the  author,  who  is  a  distinguished    I    great  practical  value." — Boston  yournal  of  Cheviis- 
Chemist,  and  has  had  great  experience  in  Sanitary  mat-        try. 
ters,  is  a  suiBcient  testimonial  to  its  accuracy  and  its    | 

PLASTICS  AND  PLASTIC  FILLING; 

As  Pertaining  to  the  Filling  of  all  Cavities  of  Decay  in  Teeth  below  Medium  in 
Structure,  and  to  Difficult  and  Inaccessible  Cavities  in  Teeth  of  all  Grades  of 
Structure.  With  some  beautifully  executed  Illustrations.  By  J.  Foster  Flagg, 
D.D.S.;  Professor  of  Dental  Pathology  and  Therapeutics  in  Philadelphia  Dental 
College.  In  one  handsome  Octavo  Volume,  bound  in  Beveled  Cloth.  Price 
$3.00. 

Article  ii.  The  Insertion  of  Amalgam  Fillings. 

"       12.  General  considerations  pertaining  to  Amal- 


Introductorj'. 

Article  i,.  Plastic  Filling. 

"        2.  Amalgam. 

"        3.         do.  Continued. 

'■         4.         do.  do. 

"-        5.  Attributes  of  metals  used   for  Amalgam 
alloys. 

"        ft.  The  Making  of  Amalgam  Alloys. 

"         7.  Tests  for  Amalgam. 

"         8.  Preparation  of  Cavities. 

"        9.  The  making  of  Amalgam. 

"       10.  Instrument  for  the  insertion  of  Amalgam 
Fillings. 


gam. 

13.  Gutta-percha. 

14.  Oxy-chloride  of  Zinc. 

15.  Oxy-sulphate  of  Zinc. 

16.  Zinc  Phosphate. 

17.  Temporary  Stopping. 

18.  Technicalities. 

Conclusion. 


AN  ATLAS  OF  HUMAN  ANATOMY.  Sold  only  by  Subscription. 
Illustrating  most  of  the  ordinary  Dissections,  and  many  not  usually  practiced 
by  the  Student.  By  Rickman  J.  Godlee,  M.S.,  f.r.c.s.,  Assistant-Surgeon  to 
University  College  Hospital,  and  Senior  Demonstrator  of  Anatomy  in  Univer- 
sity College.  With  48  Plates  (112  figures),  exhibiting  in  color  the  Muscles,  Ar- 
teries, Veins,  and  Nerves.  Large  Imperial  Quarto,  with  a  separate  volume  of 
Explanatory  Text,  with  many  Engravings.     460  pp.     8vo.     Price  $30.00. 


"  There  is  probably  no  other  atlas  published  which 
is  entirely  the  work  of  one  man — dissections,  drawing, 
and  text.  TTiis  is  the  case  in  the  work  before  us,  and 
Mr.  Godlee  is  therefore  to  be  specially  congratulated 
in  his  threefold  cap.^city  of  anatomist,  artist,  and  au- 
thor. We  must  express  our  great  satisfaction  with  the 
work.  It  will  doubtless  become  as  popular  as  any  of 
its  predecessors,  and  will  possess  over  them  the  ad- 


vantage of  having  been  executed  by  one  who  is  an 
anatomist  as  well  as  a  surgeon." — Medical  Times  and 
Gazette. 
"  A  most  excellent  guide  to  the  student." — Lancet. 

"  The  extreme  value  of  the  plates  has  been  again 
and  again  testified  to  us  by  students  who  have  derived 
the  surest  assistance  from  them." — Student's  journal. 


RECENT  PUBLICA  TIONS. 


PRACTICAL  HISTOLOGY  AND  PATHOLOGY. 

By  Heneage  Gibbes,  m.b.     i2mo.     Cloth.     Price  $i.oo. 


CHAP.  I.  Introduction. 

"      2.  On  Preparing  Tissues  for  E.tamination. 

"      3.  On  Cutting  Sections. 

"      4.  On  Staining. 

"      5.  On  Double  Staining. 

"Our  impressions  are  decidedly  in  favor  of  the  book. 
It  is  a  clear  and  well  "written  introduction  to  the  sub- 
ject."— Medical  Times. 

This  excellent  little  work  is  admirably  adapted  to 
fulfill  the  purpose  for  which  it  has  been  written.     It  is 


CHAP.  6.  On  Mounting. 

"  7.  Method  of  Obtaining  Animal  Tissues,  etc.. 
Practical  Histology,  Pathology,  Memoranda 
and  Formulae. 


short,  clear,  and  eminently  practical.  The  author  is 
evidently  an  accomplished  histologist,  and  his  book 
conveys  the  impression  that  it  is  based  upon  his  own 
personal  experience." — The  Londoti  Medical  Record. 


Sir  Joshua  Reynold's  portrait  is  an  e.xcellent  reproduc- 
tion, and  forms  a  fitting  and  handsome  frontispiece. 

"The  volume  will  prove  an  ornament  to  the  study 
table,  where  it  will  be  a  constant  incentive  to  whatever  is 
best  and  noblest  in  a  noble  profession." — Boston  Med. 
and  Surreal  journal. 


JOHN  HUNTER  and  His  Pupils. 

By  S.  D.  Gross,  m.d.  ,  Professor  of  Surgery  in  Jefferson  Medical  College,  Phila- 
delphia, with  a  beautifully  executed  full  length  Portrait  of  the  Author  in  his 
Study.     A  Handsome  Octavo  volume.    Bound  in  Beveled  Cloth.     Price  ^1.50. 

"  It  is  refreshing  to  repd  the  story  of  a  life  so  fully 
devoted  to  science,  and  the  reader  will  readily  appre- 
ciate Professor  Gross's  enthusiasm  for  his  subject, 
which  led  him  to  extend  what  was  originally  intended 
for  an  essay  to  its  present  size. 

"  The  prototype  of  Sharp's  well-known  engraving  of 

PORTRAIT  OF  HUNTER. 

From  Sharp's  well-known  Engraving;  a  copy  of  Sir  Joshua  Reynold's  Portrait. 
For  Framing.  Large  Size,  9  x  16;  Sheet  16  x  20.  Price,  in  the  Sheet,  sent  free 
by  mail,  50  cents  ;  or,  Handsomely  Framed  $2.00. 

ILLUSTRATIONS  OF  CLINICAL  SURGERY.     Part  14. 

Consisting  of  Plates,  Photographs,  Wood  cuts.  Diagrams,  &c.,  Illustrating  Sur- 
gical Diseases,  Symptoms,  and  Accidents,  also  Operative  and  other  Methods  of 
Treatment.  By  Jonathan  Hutchinson,  f.r.c.s.,  Senior  Surgeon  to  the  London 
-Hospital.  Fasciculus  14.  Just  Ready.  With  Colored  Plates  and  Descriptive 
Letterpress.     Imp.  4to.     Price  $2.50. 

%*  Vol.  I,  containing  fasciculi  I  to  X.  Handsomely  Bound,  with  Appendix  and 
Index.     Price  $25.00. 


"  This  is  a  most  valuable  and  interesting  work." — 
Dubli7i  Medical  jfoumal. 


"  The  whole  book  is  one  singularly  rich  in  instruc- 
tion, and  in  every  sense  honorable  to  English  Surgery." 
^-British  JMedical  Journal. 

THE  MANAGEMENT  OF  CHILDREN  in  Health  and  Disease. 


-By  Mrs.  Amie  M.  Hale,  m.d. 
Cloth.     Price  50  cents. 


A  book  for  Mothers.     Second  Edition.   i2mo. 


"  Altogether,  it  is  a  book  which  ought  to  be  put  into 
every  baby  basket,  even  if  some  lace-trimmed  finery 
is  left  out,  and  should  certainly  stand  on  every  nursery 
bureau." — Philadelphia  Public  Ledger. 

"  Marked  with  good  sense,  simplicity  and  helpful- 
ness in  an  unusual  degree." — Boston  journal. 

"  Admirable  common-sense  advice,  which  mothers 
would  do  well  to  have." — Southern  Churchman. 


"The  importance  of  this  book  cannot  be  over  esti- 
mated."— N.  E.  journal  oj"  Education. 

"Abounds  in  valuable  information." — Therapeutic 
Gazette. 

"  Admirably  simple,  clear,  sensible,  and  safe  in  its 
teachings." — Friends'  Revieiv. 

"  It  should  be  upon  every  household  table." — Nash- 
ville yournal  o/  Med.  and  Surg. 


MEDICAL  EDUCATION  and  Practice  in  All  Parts  of  the  World. 

By  Herbert  Junius  Hardavicke,  m.d.,  m.r.c.p.     8vo.     Price  $3.00. 

"  Dr.  Hardwicke's  book  will  prove  a  valuable  source  the  remotest  corners  of  the  earth.     The  work  has  bgen 

of  information  to  those  who  may  desire  to  know  the  compiled  with  great  care,  and  must  have  required  a 

conditions  upon  which  medical  practice  is  or  may  be  vast  amount  of  labor  and  perseverance  on  the  part  of 

pursued  in  any  or  every  country  of  the  world,  even  to  its  author." — Dubli?i  Medical  yournal. 


PRESLEY  BLAKISTON'S 


PHYSIOLOGY   AND  HYGIENE  OF  THE  VOICE. 

With  especial  reference  to  its  Cultivation  and  Preservation.  For  the  Use  of 
Speakers  and  Singers.  By  Gordon  Holmes,  l.r.c.p.  Edin.,  Physician  to  the 
Municipal  Throat  and  Ear  Infirmary.     Crown  8vo.     Illustrated.     Price  $2.00. 

*:!:*  The  chief  aim  of  this  treatise  is  to  furnish  persons  who  make  an  artistic  or  professional  use  of  the  vocal 
organs  with  a  concise  but  complete  account  of  those  scientific  relations  of  the  voice,  physical  and  medical,  which 
are  generally  only  alluded  to  cursorily,  or  passed  over  altogether  in  works  on  elocution  and  singing. 


"  Mr.  Holmes  has  evidently  qualified  himself  for  the 
study  by  researches  into  the  phenomena  and  abstract 
theory  of  ionni." —Saturday  Review. 

"The  author  gives  a  historical  review  of  the  origin 


and  progress  of  vocal  culture,  and  considers  the  relation 
of  sound  to  the  voice,  the  physical  construction  of  the 
vocal  organs,  their  physical  action,  the  physiological 
principles  involved,  and  the  hygiene  of  the  voice." — 
Popular  Science  Monthly. 


LARYNGOSCOPY  AND  RHINOSCOPY.     Including  the  Diag- 
nosis of  the  Diseases  of  the  Throat  and  Nose. 

By  Prosser  James,  m.d.     Third  Edition.     With  Colored  Plates.     Price  ^2.00. 

BY  THE   SAME  AUTHOR. 
SORE  THROAT :  Its  Nature,  Variety  and  Treatment,  Including  the  Connections  between  Affec- 
tions of  the  Throat  and  other  Diseases. 

4th  edition.     Colored  Plates  and  Engravings.     Price  $2.25. 


"  It  is  a  small  work,  and  yet  it  comprises  just  what 
the  busy  practitioner  wants." — Southern  Practitioner . 

"  To  say  that  the  book  is  an  excellent  one,  is  only  to 


say  what  every  one  familiar  with  the  author's  reputation 
already  knows." — Monthly  Review. 

"  We  can  confidently  recommend." — British  Medical 
yournal. 


DRUGS   THAT    ENSLAVE.     The  Opium,  Morphine,   Chloral, 
and  Hashisch  Habits. 

"  They  are  drunk,  but  not  with  wine.     They  stagger,  but  not  with  strong  drink." — Isaiah. 

By  H.  H.  Kane,  m.d.,  of  New  York  City.  One  volume.  i2mo.  With 
Illustrations.     Price  $1.50. 

A  curse  that  is  daily  spreading,  that  is  daily  rejoicing  in  an  increased  number 
of  victims,  that  entangles  in  its  hideous  meshes  such  great  men  as  Coleridge, 
De  Quincey,  William  Blair,  Robert  Hall,  John  Randolph,  and  William 
Wilberforce,  besides  thousands  of  others  whose  vice  is  unknown,  should 
demand  a  searching  and  scientific  examination. 

"  A  vivid  and  startling  expose  of  the  increase  of  this 
form  of  intemperance,  and  the  terrible  sufferings  en- 
dured  by  those   trying  to  free   themselves  from   this 


habit." — Pittsburg  Telegraph. 

"  It  is  well  that  such  a  warning  as  is  contained  in 
this  book  should  be  sounded." — Albany  Evening 
yournal. 

"  The  volume  seems  to  be  a  summary  of  the  results 
of  the  most  approved  practice,  both  in  Europe  and 
this  country." — Ne^u   York   World. 

"  This  excellent  publication  we  commend  to  the  at- 
tention of  the  reading  public." — Philadelphia  Record. 

"  A  work  of  more  than  ordinary  ability  and  careful 
research.     .     .     .     For  the  first  time,  reliable  statis- 


"  The  effects  of  the  habits  described  are  set  forth 
boldly  and  clearly,  and  the  book  must  have  a  beneficial 
effect.  It  will  do  still  better  service  in  deterring  per- 
sons from  experimenting  'to  see  what  it  is  like.'  " — 
Charleston  (S.  C.)  News  and  Courier. 

"  It  contains  a  large  amount  of  information  collected 
with  much  labor  and  presented  in  a  systematic  manner. 
The  subject  of  the  chloral  habit  has  not  been  investi- 
gated by  any  one,  we  believe,  so  thoroughly  as  by  Dr. 
Kane." — Medical  Record. 

"  There  is  ground  for  a  new  temperance  movement 
here.  The  book  is  a  valuable  one.  It  is  written  in  a 
practical  manner,  and  has  nothing  of  a  sensational 
character." — Philadelphia  Ledger. 


tics  on  the  use  of  chloral  are  classified  and  published.  \        "  It  deserves  to  be  read  by  those  who  feel  an  interest 

.     .     .     .     and  it  is  shown  that  the  use  of  chloral  ';    in   discouraging  the   use   of   these    dangerous   drugs. 

causes  a  juore  complete  atid  rapid  ruin  0/ mind  and  The  book  is   embellished   by  an  excellent   phototype 

body  than    either  opium  or   morphine." — Druggists'  frontispiece    of    Laocoon." — American    yournal   of 

Circular  and  Gazette.  |     rharmacy. 

AN  INTRODUCTION  TO  PHARMACEUTICAL  AND  MED- 
ICAL CHEMISTRY.    Part  One. — Theoretical  and  Descriptive.  Part 
Two. — Practical  and  Analytical. 

Arranged  on  the  Principle  of  the  Course  of  Lectures  on  Chemistry  as 
Delivered  at,  and  the  Instruction  Given  in  the  Laboratories  of,  the  South  London 
School  of  Pharmacy.  By  John  Muter,  m.a.,  President  of  the  Society  of  Pubhc 
Analysts,  etc.  A  Second  Edition  Enlarged  and  Rearranged.  The  Two  Parts 
bound  in  one  large  octavo  volume.     Price  ^6.00. 


RECENT  PUB  Lie  A  TIONS. 


A    GUIDE    TO     THE     EXAMINATION    OF    THE    URINE; 
Intended  Chiefly  for  Clinical  Clerks  and  Students. 

Fifth  Edition,  revised  and  enlarged,  with  additional  Illustrations. 

By  J.  WiCKHAM  Legg,  F.R.C.P.,  Assistant  Physician  to  Saint  Bartholomew's 
Hospital,  and  Lecturer  on  Pathological  Anatomy  in  the  Medical  School.  i6mo. 
Price  75  cents. 


"  Is  distinguished  by  its  great  accuracy  and  concise- 
ness .  .  .  there  could  not,  for  its  size,  be  a  better 
manual  ...  it  would  be  difficult  to  find  such  an 
amount  of  useful,  sound  information  condensed  into  io6 
small  pages  of  clear,  readable  type." — Dublin  Journal 
of  Medical  Science ,  July,  1880. 


"  We  are  glad  to  welcome  this  little  work  .  .  . 
Just  what  was  wanted." — British  Medical  yournal. 

"  Is  an  admirable  guide  to  the  clinical  examination 
of  the  urine  ...  A  most  excellent  and  useful 
work." — Edin.  Med.  your. 


MARTIN'S  ATLAS  OF  OBSTETRICS  AND  GYNAECOLOGY. 


Edfted  by  A.  Martin,  Docent  in  the  University  of  Berlin.     Translated  and 
Edited  with  Additions,  by  Fancourt  Barnes,  m.d.,  m.r.c.p.,  Physician  to  the 
British  Lying-in  Hospital ;  Assistant  Physician  to  the  Royal  Maternity  Charity 
of  London,  etc.     A  Thick  Quarto  Volume,  Handsomely  Bound  in  Cloth. 
Price  |i2.oo.     Sold  Only  by  Subscription. 


"  This  valuable  and  classic  series  of  illustrations, 
first  published  by  Professor  Edward  Martin  in  1S61, 
has  long  had  a  great  reputation  in  Germany  as  being  of 
great  service  to  practitioners  as  well  as  students  of  mid- 
wifery. It  includes  98  pages  of  plates,  with  an  average 
of  5  illustrations  on  each,  many  of  which  are  colored, 
and  some  drawn  on  a  large  scale,  so  as  to  occupy  the 
whole  page,  where -this  has  seemed  desirable.  The 
subjects  treated  range  through  the  whole  of  midwifery 
and  gynsecology,  beginning  with  normal  and  abnormal 
pelves,  and  ending  with  illustrations  of  some  of  the 
most  important  obstetric  gj'naecologic  instruments 
used  in  Germany  and  in  this  country.  .  .  The  de- 
scriptive letter-press  is  very  full  and  accurate,  and  the 
whole  makes  an  extremely  handsome  volume,  of  portly 


yet  not  of  cumbrous  size.     This  atlas  has  nothing  of  its 
kind  to  compete  with  it  in  the  English  language,  and 
will   no   doubt   be  warmly  welcomed   by  obstetricians 
and  gjmaecologists  and  students  of  the  advanced  class, 
— British  Medical  Journal,  July  loth,  1880. 

"The  atlas  is  the  most  complete  and  comprehensivi 
work  of  its  kind.  .  .  Nearly  every  point,  anatomi 
cal,  physiological,  obstetrical,  and  gynaecological,  is 
illustrated  in  the  best  way  by  well  known  authors 
from  whose  works  the  late  Dr.  Martin  culled  his  illus- 
trations. As  a  work  of  reference  to  the  practitioner, 
the  atlas  is  invaluable ;  while  to  the  student  who  wishes 
to  refresh  his  memory  in  the  readiest  way,  and  in  the 
shortest  time,  it  will  be  very  useful." — Lo?idon  Medical 
Record,  July  15th,  1880. 


THE  DISEASES  OF  THE  THROAT  AND  NOSE, 

Including  the  Pharynx,  Larynx,  Trachea,  CEsophagus,  Nasal  Cavities,  and 
Neck.  By  Morell  Mackenzie,  m.d.  London,  Senior  Physician  to  the  Hos- 
pital for  Diseases  of  the  Chest  and  Throat,  Lecturer  on  Diseases  of  the  Throat 
at  London  Hospital  Medical  College,  etc.,  etc.  Vol.  i,  containing  The  Pharynx 
Larynx  and  Trachea,  with  112  Illustrations.  Now  ready.  Price,  in  Cloth,  ^4.00; 
Sheep,  $5.00, 

Published  from  early  sheets,  by  arrangement  with  Dr.  Mackenzie.  Vol.  2,  in 
Preparation. 


"  We  have  long  felt  the  want  of  a  thoroughly  practi- 
cal and  systematic  treatise  on  diseases  of  the  throat 
and  nasal  passages.  Admirable  essays  have  from  time 
to  time  appeared  ;  no  standard  work  has  been  written. 
Any  one  familiar  with  laryngoscopic  work  must  appre- 
ciate the  valuable  addition  now  made  to  this  special 
department  in  the  work  before  us.  The  entire  work, 
of  which  only  the  first  volume  has  as  yet  appeared, 
will  include  the  consideration  of  affections  of  tlie  pha- 
rynx, larynx,  trachea,  oesophagus,  nasal  cavities,  and 
neck.  The  matter  now  presented  complete  for  the  first 
time  is  the  result  of  the  author's  large  and  unrivaled 
experience,  both  in  hospital  and  private  practice,  ex- 
tending over  a  period  of  twenty  years. 

"  There  can  be  but  one  verdict  of  the  profession  on 
this  manual — it  stands  without  any  competitor  in  med- 
ical literature,  as  a  standard  work  on  the  organs  it  pro- 
fesses to  treat  of." — Dublin  Journal. 


"The  first  volume  of  Dr.  Mackenzie's  long  prom- 
ised work  is  at  hand.  Should  the  second  volume  sus- 
tain the  high  character  of  labor  so  evident  in  the  first, 
the  completed  work  will  take  a  high  position  in  the 
branch  of  medicine  of  which  it  treats.  It  is  both  prac- 
tical and  learned  ;  it  is  abundantly  and  well  illustrated  ; 
its  descriptions  of  disease  are  graphic,  and  the  diagno- 
ses the  best  we  have  anywhere  seen.  To  give  exam- 
ples of  the  thoroughness  of  Dr.  Mackenzie's  book,  we 
may  cite  the  chapter  on  diphtheria,  which  embraces  47 
pages.  The  chapter  on  non-malignant  tumors  of  the 
larynx  would  appear  to  be  absolutely  exhaustive.  No- 
where else  have  we  seen  so  elaborate  a  statement  of  the 
subject. 

"  We  can  predict  for  this  work  a  high  position,  and 
congratulate  its  distinguished  author  upon  its  appear- 
ance."— Philadelphia  Medical  Times. 


I o  PRESLE  V  BLA  KIS TON' S 

BY   SAME  AUTHOR.       [MORELL  MACKENZIE,  M.D.] 

THE    PHARMACOPCEIA   of  the    Hospital   for  Diseases   of  the 
Throat  and  Nose. 

The  Fourth  Edition,  much  enlarged,  containing  250  Formulse,  with  Directions 
for  their  Preparation  and  Use.     i6mo.     Cloth.     Price  $1.25. 

DIPHTHERIA'     Its  Nature  and  Treatment.     i2mo.     Price  75  cts. 

THE  SPECTROSCOPE  IN  MEDICINE. 

By  Charles  A.  MacMunn,  b.a.,  m.d.  8vo,  with  3  Chromo-lithographic 
Plates  of  Physiological  and  Pathological  Spectra,  and  13  Engravings.  Price  $3.00. 

"  It  is  painstaking  throughout ;  it  aims  not  at  bril-  I    we  may  safely  rely  on  the  conclusion  of  the  author." — 
liancy  but  at  accuracy ;  and  the  result  is  that  we  feel   |    Medical  Times  and  Gazette. 

OLDBERG.     AN  UNOFFICIAL  PHARMACOPCEIA. 

Comprising  over  700  Popular  and  Useful  Preparations  not  Official  in  the 
United  States,  and  the  Metric  System  of  Weights  and  Measures,  a  Metric  Dose. 
Table,  and  300  Illustrations  of  Metric  Prescription  Writing.  By  Oscar  Old- 
berg,  PHAR.  D.,  Medical  Purveyor,  United  States  Marine  Hospital  Service  ; 
Professor  of  Materia  Medica,  National  College  of  Pharmacy,  Washington,  D.  C; 
Member  of  the  American  Pharmaceutical  Association,  and  of  the  Sixth  Decen- 
nial Committee  of  Revision  and  Publication  of  the  Pharmacopoeia  of  the 
United  States,  etc. 

This  volume  contains  practical  and  tried  working  formulae  for  over  seven  hundred  Unofficial  but  Popular 
Preparations,  among  which  are  the  various  elixirs,  fluid  extracts,  mixtures,  syrups,  tinctures,  ointments,  wines, 
etc.,  in  demand  all  over  the  country.  It  will  prove  a  useful  supplement  to  the  Pharmacopoeia  of  the  United  States. 
The  aim  has  been  to  make  it  as  complete  as  practicable.  The  formuloe  can,  with  a  minimum  of  labor,  be  used 
with  any  system  of  weights  and  measures,  as  all  the  numbers  opposite  the  several  ingredients  refer  to  but  one  unit, 
or  to  the  gram  for  solids,  and  the  corresponding  fluigram  for  liquids.  Either  ounces,  drachms,  or  any  other  unit, 
may  be  substituted  for  grams.  The  virtual  adoption  of  the  metric  system  in  the  forthcoming  Pharmacopoeia  of 
the  United  States  will  account  for  the  preference  given  to  that  system  in  this  volume,  which,  however,  does  not 
prevent  the  ready  use  of  the  book  with  apothecaries'  weights  and  measures.  An  extended  account  of  the  metric 
system  has  been  given,  accompanied  by  full  tables  of  equivalents. 

The  .sources  from  which  the  formulae  have  been  gathered  are  believed  to  be  the  best.  They  include  the 
Pharmacopoeias  of  England,  Germany,  France  and  Sweden,  and  the  formulae  were  selected  with  reference  to  their 
popularity,  usefulness,  and  interesting  character.  Several  are  from  the  Reports  of  the  American  Pharmaceutical 
Association  (especially  the  Report  on  the  Revision  of  the  Pharmacopoeia,  edited  by  Charles  Rice,  of  New  York), 
and  others  are  original. 

BY   THE   SAME   AUTHOR. 

THE  METRIC  SYSTEM  PRESCRIPTION  BOOK. 

Comprising  an  account  of  the  Metric  System,  prepared  expressly  for  the  use 
of  Students  of  Medicine  and  Pharmacy,  together  with  300  Metric  Prescriptions, 
selected  chiefly  from  the  best  collections  of  Formulae  used  in  Hospital  and  out- 
patient practice,  and  a  complete  Dose  Table  ;  designed  as  an  aid  in  Metric  pre- 
scription writing.     By  Oscar  Oldberg,  phar.  d. 

'  The  metric  prescriptions  given  in  this  work  are  selected  from  the  Pharmacopoeias  and  formularies  of  the 
great  hospitals  of  New  York,  Philadelphia,  Boston  and  London,  or  contributed  from  the  practice  of  medical  offi- 
cers of  the  United  States  Marine  Hospital  Service.  Most  of  them  are,  in  fact,  extensively  employed  in  hospital 
and  out-patient  practice,  and  they  have  been  slightly  altered  in  converting  them  into  metric  terms,  and  adjusted 
to  a  final  product  of  one  hundred  units. 

The  Dose  table  probably  includes  nearly  all  of  the  remedies  that  have  a  place  in  the  current  Materia  Med- 
ica. The  Latin  nomenclature  used  is  in  accordance  with  the  views  expressed  in  a  paper  read  before  the  Ameri- 
can Pharmaceutical  Association,  at  Saratoga,  N.  Y.,  in  September  last.  In  it  the  possessive  case  is  ignored,  and 
the  names  of  chemicals  are  simply  latinizations  of  the  most  correct  English  chemical  nomenclature. 


RECENT  PUBLICA  TIONS. 


THE  ART  OF  PERFUMERY. 

The  Methods  of  Obtaining  the  Odors  of  Plants  and  Instruction  for  the  Manu- 
facture of  Perfumery,  Dentrifices,  Soap,  etc.,  etc.  By  G.  W.  Septimus  Piesse. 
4th  edition,  enlarged.     366  illustrations.     8vo.     Cloth.     Price  $5.50. 

"  An  excellent  book." — Commercial  Advertiser.  I        "Exceedingly  useful  to  druggists  and  perfumers." — 

"  It  is  the  best  book  on  Perfumery  yet  published."—        Journal  of  Chemistry .  _      „      ,^  v     / 

Scientific  American.  '  '      >"  |        "  Is  in  the  fullest  sense,  comprehensive.   —il/^^^c«/ 

Record. 

MEDICAL  HERESIES,  HISTORICALLY  CONSIDERED; 

A  Series  of  Critical  Essays  on  the  Origin  and  Evolution  of  Sectarian  Medi- 
cine, embracing  a  Special  Sketch  and  Review  of  Homoeopathy,  Past  and 
Present.  By  Gonzalvo  C.  Smythe,  a.m.,  m.d..  Professor  of  the  Principles 
and  Practice  of  Medicine,  College  of  Physicians  and  Surgeons,  Indianapolis, 
Indiana.     i2mo.     Cloth.     Price  $1.25. 


"  This  book  gives,  in  a  small  compass,  an  excellent 
history  of  medicine,  from  its  earliest  day  to  the  present 
time.  ...  It  will  undoubtedly  be  interesting  to  a 
large  part  of  the  reading  public." — Bziffalo  Medical 
a7id  Surgical  jfournal. 

"  Students  and  others  interested  in  the  subject  of 
medicine  will  find  a  digest  of  the  entire  controversy 
(between  the  various  schools  of  medicine)  ably  pre- 
sented in  this  well-printed  volume."- — Journal  of  Edu- 
cation. 

"  Professor  Smythe  has  succeeded  in  writing  a  brief. 


clear,  and  interesting  sketch  of  the  evolution  of  medi 
cal  eccentricities,  and  of  modem  homoeopathy,  its  facts 
and  fallacies.  We  commend  the  work." — Philadelphia 
Medical  Times. 

"  Cannot  fail  to  be  of  interest,  not  only  to  the  medi- 
cal profession,  but  to  the  general  reader." — Baltimore 
Gazette. 

"  Dr.  Smythe  is  a  clear  and  forcible  writer." — Cin- 
cinnati  Gazette. 

"  The  book  will  instruct  as  well  as  interest." — In' 
diana  Farmer. 


SYLLABUS  OF  LECTURES  ON  PHYSIOLOGY. 

By  J.  BuRDON  Sanderson,  m.d.,  ll.d.,  f.r.s.,  Professor  of  Physiology  in  Uni- 
versity College,  London.     Second  Edition.     8vo.     Price  $1.50. 

"  Notes  of  a  course  of  lectures  by  such  an  able  phy- 
siologist and  such  an  experienced  teacher  as  Dr.  San- 
derson cannot  but  be  welcome  to  every  student  and 
teacher  of  physiology.  .  .  .  It  is  surprising  what 
an  enormous  amount  of  matter  is  condensed  into  so  few 
pages.     There  is  scarcely  a  fact  of  importance  which 


does  not  find  mention,  and  the  whole  is  written  in  the 
accurate,  pointed  style  which  distinguishes  all  the 
writings  of  the  author.  We  think  this  work  will  be 
found  most  useful  to  all  students  of  physiology." — 
Dublin  Jour.  Med.  Science,  March  1880. 


RINGWORM:  Its  Diagnosis  and  Treatment. 

By  Alder  Smith,  m.d.  Lond.,  f.r.c.s..  Resident  Medical  Officer  Christ's  Hos 
pital,  London.     With  Illustrations.     i2mo.     Cloth 


"  A  strongly  practical  and  sound  exposition  of  the 
diagnosis  and  treatment  of  the  several  kinds  of  com- 
mon ringworm." — London  Lancet. 


Price  %\.oQ. 

"  We  should  say  that  it  is  sound,  instructive,  and 
altogether  satisfactory." — Medical  and  Surgical  Re- 
porter. 


PHYSICAL   DIAGNOSIS   OF  DISEASES  OF  THE  HEART, 
Including  the  Use  of  the  Sphygmograph  and  Cardiograph. 


Third  Edition,  with  47  Woodcuts 
Sansom,  m.d.,  f.r.c.p.  Lond.,  Senior 
for  Children,  Assistant  Physician  to 
Price  $2.50. 

"  This  work  is  replete  with  information,  and  will 
well  repay  a  careful  perusal.  Thoroughly  practical  in 
character,  it  gives  in  clear  language,  and  in  a  methodi- 
cal manner,  every  point  which  calls  for  inquiry  in  the 
investigation  of  cardiac  disease." — London  La-ncet. 

"  Dr.  Sansom  writes  as  only  a  man  who  is  a  thorough 
master  of  his  subject  can  write.     He  gives  abundant 

SYNOPSIS  OF  PHYSIOLOGICAL  ACTION   OF  MEDICINE. 

"  A  Chart  of  the  Physiological  Action  of  Medicines."  Second  Edition.  En- 
larged and  Rearranged  by  Louis  Starr,  m.d.,  and  James  B.  Walker,  m.d. 
i2mo.     Paper.     Price  50  cents. 


about  300  pp.,  F.cap.  8vo.  By  A.  E. 
Physician  to  the  Northeastern  Hospital 
the    London    Hospital.      i2mo.      Cloth. 


proof  that  his  reading  has  been  as  extensive  as  his 
practical  experience.  He  rides  no  hobbies  and  airs  no 
crotchets,  but  is  content  to  give  us,  as  shortly  as  possible, 
all  the  well-established  facts  connected  with  the  physi- 
cal diagnosis  of  heart  disease." — Medico- Chirurgical 
Review,  July,  1877. 


PRESLEY  BLAKISTON'S 


VETERINARY  PHARMACOPCEIA  : 

Including  the  Outlines  of  Materia  Medica  and  Therapeutics,  for  the  use  of 
Practitioners  and  Students  of  Veterinary  Medicine.  By  Richard  V.  Tuson,  f.c.s. 
Professor  of  Chemistry,  Materia  Medica,  and  Toxicology,  at  the  Royal  Vet- 
erinary College.     Third  edition.     Post  8vo.     ;g2.5o. 

to  prove  of  the  greatest  value  to  practitioners  of  vet- 


"  Appears  to  be  very  complete,  is  gotten  up  m  first- 
class  style,  and  has  an  index  appended.     It  cannot  fail 


erinary  medicine." — Medical  and  Surgical  Reporter. 


PRACTICAL  LITHOTOMY  AND  LITHOTRITY  ; 

Or,  an  Inquiry  into  the  best  Modes  of  Removing  Stone  from  the  Bladder.     By 
Sir  Henry  Thompson,  f.r.c.s.,  Emeritus  Professor  of  Clinical  Surgery  in  Uni- 


With  87  Engravings.     Price  $3.50. 

"The  chapters  of  most  interest  are  those  in  which 
Bigelow's  operation  is  discussed,  and  the  final  one,  in 
which  is  a  record  of  500  operations  for  stone  in  cases  of 
male  adults  under  the  author's  care.  Such  a  table  has 
never  before  been  compiled  by  any  surgeon." — Lancet. 


versity  College.     Third  edition.     Svo. 

"  Catholic  in  his  investigation  of  the  fruit  of  the 
labor  of  others,  cautious  in  all  his  deductions,  reject- 
ing all  specious  theories  in  the  effort  to  obtain  practi- 
cally useful  results,  as  clever  with  his  pen  as  he  is  with 
the  sound  or  lithotrite,  one  can  scarcely  wonder  that  he 
is  esteemed  the  master  thathe  is." — American  yourn. 
of  Med.  Sci. 

OTHER   BOOKS   BY   THE   SAME   AUTHOR. 
DISEASES  OF  THE  URINARY  ORGANS.     Clinical  Lectures.     Fifth  edition 

71  Engravings.     Price  $3.50. 
DISEASES  OF  THE  PROSTATE.     Their  Pathology  and  Treatment.     Fourth  edition 

ous  Plates.     Price  ^4.00. 
THE    PREVENTIVE    TREATMENT   OF    CALCULOUS   DISEASE,   and   the    Use    of    Solvent 
Remedies.     Second  edition.     i6mo.     Price  $1.00. 

POST-MORTEM  EXAMINATIONS. 

A  Description  and  Explanation  of  the  Method  of  Performing  them  in  the 
Dead  House  of  the  Berlin  Charite  Hospital,  vi^ith  especial  reference  to  Medico- 
Legal  Practice.  By  Prof.  Virchow.  Translated  by  Dr.  T.  P.  Smith.  Second 
edition.     i2mo,  w^ith  4  Plates.     Price  $1.25. 


8vo.     With  2  Plates  and 


Svo.     With  numer- 


"Its  low  price  and  portability  make  it  accessible  and 
convenient  to  every  surgical  registrar  and  practitioner." 
— British  Medical  jfournal. 


"A  most  useful  manual  from  the  pen  of  a  master. 

.  .  .  .  For  thorough  and  systematic  method  in 
the  performance  of  post-mortem  examinations,  there  is 
no  guide  like  it." — Lancet. 

DRAINAGE  FOR  HEALTH  ; 

Or,  Easy  Lessons  in  Sanitary  Science 
Wilson,  m.d.,  Late  Medical  Director 
Price  ^i.oo. 

"  Dr.  Wilson  is  favorably  known  as  one  of  the  lead- 
ing American  writers  on  hygiene  and  public  health. 
Tlie  book  deserves  ■^o-^uXz.riX.y ." —Medical  and  Surgi- 
cal Reporter. 

"  Well  written  and  well  illustrated.  Attention  to 
its  teachings  may  save  much  disease  and  perhaps  many 
lives." — Cincinnati  Gazette. 

"  Interesting  as  well  as  useful." — Philadelphia  Led- 
ger. 

WILSON'S  ANATOMIST'S  VADE-MECUM.     Tenth  Edition. 
By  George  Buchanan,  Professor   of  Clinical   Surgery   in   the   University   of 
Glasgow  ;  and  Henry  E.  Clark,  Lecturer  on  Anatomy  at  the  Royal  Infirmary 
School  of  Medicine,  Glasgow.     Tenth  edition.     With  450  Engravings  (including 
26  Colored  Plates).     Crown  Svo,  Price  $6.00. 


with  numerous  Illustrations.     By  Joseph 
United  States  Navy.     One  Vol.   Octavo. 


"  Easily  understood,  and  briefly  and  concisely  pre- 
sented."— Provide}ice  yournal. 

"  Will  be  found  of  value." — Boston   Transcript. 

"  Worthy  of  praise  as  a  popular  statement  of  the 
subject." — Boston  yournal  of  Chemistry. 

"  Will  be  sure  to  be  a  harbinger  of  good  in  every  fam- 
ily whose  good  fortune  it  may  be  to  possess  a  copy." — 
Builder  and  Wood  Worker. 


PREFACE. 

"  The  present  edition  of  the  '  Anatomist's  Vade- 
Mecum'  has  been  prepared  under  the  same  editorial 
control  as  the  Ninth  Edition.  Dr.  George  Buchanan 
gives  a  general  supervision  to  the  work,  and  to  those 
parts  bearing  directly  on  surgical  practice.  Henry  E. 
Clark  in  making  a  general  revision  has  left  his  mark  on 
every  page  of  the  book,  writing  those  new  descriptions 
rendered  necessary  by  the  more  extended  and  exact 
knowledge  of  recent  years. 


"  The  most  important  changes  will  be  found  to  consist 
in  the  expansion  and  more  complete  elaboration  of  the 
section  on  Histology,  and  the  introduction  of  full-page 
plates  of  the  bones,  with  the  muscular  attachments 
shown  in  colours." 

"Numerous  additional  wood  cuts  have  been  introduced 
and  full-page  engravings  of  the  bones,  which  have  been 
drawn  and  engraved  with  great  care,  to  secure  accuracy 
and  to  make  them  not  mere  anatomical  diagrams  but 
artistic  pictures." 


RECENT  PUB  Lie  A  TIONS. 


13 


ON  DEAFNESS,  GIDDINESS  AND  NOISES  IN  THE  HEAD. 


By  Edward  Woakes,  m.d.,  London,  Surgeon  to  the  Ear  Department  of  the 
Hospital  for  Diseases  of  the  Throat  and  Chest ;  and  Surgeon  to  the  Hospital. 
Second  edition,  revisedand  enlarged,  with  additional  Illustrations.  1 2mo.  Cloth, 
Price  I2.50. 


"  The  early  demand  for  a  fresh  edition  of  Dr. 
Woakes'  Httle  volume  is  a  sufficient  criticism  of  its 
merits.  .  .  .  No  brief  summary  of  his  views  could 
do  full  justice  to  the  cogency  and  subtlety  of  his  reas- 
ons. We  prefer  to  commend  the  whole  work,  to  the 
thoughtful  perusal  of  all  intelligent  medical  practition- 
ers who  desire  to  rise  above  the  level  of  mere  routine 
empiricism." — Lancet,  August  28th,  1880. 

"  This  work  demands  the  full  attention  of  all  aural 
surgeons.     .     .     .     it  is  thoroughly  original,  and  intro- 


duces, in  a  truly  scientific  spirit,  a  great  many  new 
observations  and  new  ideas." — Dr.  Weber-Liel,  in 
Mo7iattsshrift  fiXr  Ohrenheilkunde ,  June  1869. 

"  This  book,  although  small,  is  evidently  the  result 
of  much  careful  thought  and  observation.  .  .  .  We 
cordially  recommend  the  work  as  original  and  suggest- 
ive, and  as  being  likely  to  prove  very  useful  in  explain- 
ing both  the  causation  of  symptoms  otherwise  puzzling, 
and  their  appropriate  treatment." — Practitio7ier ,  July 


HEALTH  AND  HEALTHY  HOMES. 


A  Guide  to  Personal  and  Domestic  Hygiene.  By  George  Wilson,  m.d., 
Medical  Officer  of  Health.  Edited  by  Jos.  G.  Richardson,  m.d.,  Professor  of 
Hygiene  at  the  University  of  Pennsylvania.     i2mo.     Cloth.     Price  $1.50. 


Chap.  I.  Introductory.  Page  17 

"      II.  The  Human  Body,  "     33 

"    III.  Causes  of  Disease,  "     66 

"    IV.  Food  and  Diet,  "  119 

"      V.  Cleanliness  and  Clothing,  "  169 


"  A  most  useful  and,  in  everyway,  acceptable  book." 
— Neil)  York  Herald. 

"  Marked  throughout  by  a  sound,  scientific  spirit,  and 
an  absence  of  all  hasty  generalizations,  sweeping  as- 


Chap.  VI.  Exercise,  Recreation  and  Training,  P.  187 
"      VII.  Home  and  Its  Surroundings,  Drainage, 

Warming,  etc.,  "  221 

"    VIII.  Infectious   Diseases   and  their   Pre- 
vention, "  269 


sertions,  and  abuse  of  statistics  in  support  of  the 
writer's  particular  views.  .  .  .  We  cannot  speak 
too  highljr  of  a  work  which  we  have  read  with«entire 
satisfaction." — Medical  Times  and  Gazette. 


A   HANDBOOK   OF  HYGIENE   and   Sanitary   Science, 
vised  and  Enlarged.     8vo.     Price  $2.75. 


BY   THE   SAME  AUTHOR. 

With    Illustrations.      Fourth    Edition.     Re- 


THE  OCEAN  AS  A  HEALTH  RESORT. 

A  Handbook  of  Practical  Information  as  to  Sea  Voyages,  for  the  Use.of  Tour- 
ists and  InvaHds.  By  Wm.  S.  Wilson,  l.r.c.p.  Lond.,  m.r.c.s.e.  With  a  Chart 
showing  the  Ocean  Routes,  and  Illustrating  the  Physical  Geography  of  the  Sea. 
Crown  8vo.     Price  $2.50. 


CHAP. 

1.  Curative  Effects  of  the  Ocean  Climate. 

2.  The  Various  Health  Voyages. 

3.  Time  of  Starting — Choosing  a  Ship. 

4.  Preliminary  Arrangements. 

5.  Life  at  Sea. 

6.  Climate  and  Weather. 

7.  Management  of  the  Health  at  Sea. 

8.  Occupations  and  Amusements  at  Sea. 
g.  Objects  of  Interest  at  Sea. 


CHAP. 

10.  End  of  the  Voyage — Future  Plans.  ~ 

11.  The  Homeward  Voyage. 

12.  Australia  :  its  Climate,  Cities,  and  Health  Resorts. 

13.  South  Africa  and  its  Climate. 

14.  The  Meteorology  of  the  Ocean. 

Appendix  A. — Outfit  Required  for  a  Voyage  to  Aus- 
tralia. 

Appendix  B. — Names  and  Addresses  of  some  of  the 
Principal  Shipping  Firms. 


"AH  the  information  is  supplied  by,  or  based  upon, 
the  actual  experience  of  the  author  ;  and  the  book  may 
be  Confidently  recommended  to  all  who  have  to  under- 
take, without  previous  experience,  a  sea-voyage  of  any 
length.     Medical  men  may  consult  it  with  advantage, 


and  commend  it  to  those  patients  whom  they  may  ad- 
vise to  try  the  effect  of  along  voyage  at  sea." — Med. 
Times  and  Gazette. 

"  We  have  read  every  page  of  this  book,  and  have 
derived  both  instruction  and  amusement." — Lancet. 


14  PRESLE  Y  BLAKISTON'S 


STUDENT'S  PRIMER  ON  THE  URINE. 

By  J.  Travis  Whittaker,  m.d.,  Physician  to  Anderson's  College  Dispensary. 
With  Illustrations  Etched  on  Copper.     i6mo.     Price  $1.50. 


Physiological  Study  of  Urine — 

Sensation  in  Passing — Quantity — Color —  Odor 
— Specific  Gravity — Histoi-y  and  Behavior — Sed- 
iment or  Deposits. 

Chemical  Study  of  Urine — 

Reaction  —  Albumen  —  Chlorides  —  Ammonia  — 
Urea — Phosphates — Blood— Sugar — Bile. 

Microscopical  Study  of  Urine  and  Urinary  Deposits — 
Amorphous  Urates — Uric  Acid— Triple  Phos- 
phates— Phosphate    of    Lime — Feathery    Phos- 

"  The  plates   are  possessed   of  great  versirallitude  |    suitability  of  the  etching  needle  for  delineation  of  mi- 
as  well  as  in  other  respects  admirable." — Med.  Times.         croscopical    appearances." — Bostan_^Med.   and  Stir. 

"  Neat  and  concise,  and  the  illustrations  are   very         Journal. 

good  testimony  of  the  claim  which  he  makes  of  the  | 

THE   STUDENT'S    GUIDE   TO   MEDICAL  CASE  TAKING. 

By  Francis  Warner,  m.d.,  m.r.c.p.,  etc.     i2mo.     Cloth. 


Phates — Oxalate  of  Lime — Urate  of  Soda  and  of 
Ammonia — Cystine — Tyrosine —  Leucine  —  Cho- 
lesterine  —  Epithelium  —  Fat  Globules  —  Blood, 
Epithelial,  Granular,  F'atty,  Waxy  or  Hyaline, 
and  Mucous  Casts — Mucous  Globules,  Streaks 
— Pus — Bacteria,  Vibrions — Spermatozoa — Sar- 
cinse — Blood — Mould  and  Yeast  Fungus — Ex. 
traneous  matters. 
Test  Stands,  Solutions,  Tables,  etc. 


General  Diseases — Class  i. 
"  "  "     2. 

Arthritic  Diseases. 
Diseases  of  the  Nervous  System. 
Vascular  System. 


Diseases  of  the  Respiratory  Sj'stem. 
Digestive  System. 
Liver. 

Urinary  System. 
Etc.,  etc. 


STANDARD  MEDICAL  WORKS. 

GOWERS'  MANUAL  AND  ATLAS  OF  MEDICAL  OPH- 
THALMOSCOPY. 

With  16  Lithographic  Plates  and  26  Wood  Cuts,  comprising  112  original  Illus- 
trations of  the  Changes  in  the  Eye  in  Diseases  of  the  Brain,  Kidneys,  etc.  8vo. 
Price  ^6.00. 

COBBOLD'S  PARASITES  :  A  Treatise  on  the  Entozoa  of  Man 
and  Animals,  Including  some  Account  of  the  Ectozoa. 

With  85  Engravings.     8vo.     Price  ^5.00. 

BUCKNILL  &  TUKE'S  MANUAL  OF  PSYCHOLOGICAL 
MEDICINE. 

Fourth  edition,  12  Plates  (4  being  Colored).     Large  8vo.     Price  $8.00. 

ALLINGHAM  ON  FISTULA,  HAEMORRHOIDS,  PAINFUL 
ULCER,  STRICTURE,  PROLAPSUS,  AND  OTHER  DIS- 
EASES OF  THE  RECTUM,  their  Diagnosis  and  Treatment. 

Third  edition,  Revised  and  Enlarged.     Octavo.     Price  I3.00. 

WILKES'  LECTURES  ON  PATHOLOGICAL  ANATOMY. 

By  Walter  Moxon,  m.d.,  f.r.s..  Physician  to  and  late  Lecturer  on  Pathology 
at  Guy's  Hospital.     Second  edition.  Enlarged  and  Revised.     Price  $6.00. 

PARKES'  MANUAL  OF  PRACTICAL  HYGIENE  IN  CIVIL 
AND  MILITARY  LIFE. 

Edited  by  F.  De  Chaumont,  m.d.,  f.r.s.,  Professor  of  Military  Hygiene  in 
the  Army  Medical  School.  Fifth  edition,  with  numerous  Engravings.  8vo. 
Price  S6.00. 


RECENT  PUBLICATIONS.  15 


HANDSOMELY  ILLUSTRATED  WOEKS. 


Bentley  and  Trimen's  Medicinal  Plants.  Being  Descriptions,  with  Original 
Figures,  of  the  Principal  Plants  employed  in  Medicine,  and  an  Account  of 
their  Properties  and  Uses.  Completed  in  Forty-two  Parts.  Price  2.00  each. 
With  300  Colored  Illustrations  (natural  size).  Large  8vo.  In  4  volumes.  Half 
Morocco,  and  Gilt  Top.  Price  90.00. 

»**  This  Work  is  an  iUustrated  Botanical  Guide  to  the  British,  United  States,  and  Indian 

Pharmacopoeias;  it  includes  also  other  species  employed,  or  in  common  use,  though  not  officinal. 
Each  l^late  is  accompanied  by  letier-press,  containing  a  full  description  of  the  plant  in  piain 

scientific  language,  its  nomenclature,  geographical  distribution,  properties,  uses,  etc.,  with  full 

references. 

Braune's  Atlas  of  Topographical  Anatomy.  Containing  Thirty-four  Full-jDage 
Photo-Lithographic  Plates,  after  Plane  Sections  of  Frozen  Bodies,  and  Forty- 
six  Large  Wood  Engravings.  With  Marginal  References  ;  each  Plate  accom- 
panied with  Full  Explanatory  Text.  Translated  by  Edward  Bellamy,  F.  R.  C.  S. 
A  large  Imperial  Octavo  volume. 

Price,  bound  in  cloth,  12.00;  half  morocco,  gilt  head,  14.00. 

Fox's  Atlas  of  Skin  Diseases.  Complete  in  Eighteen  Parts,  each  containing 
Four  Chromo-lithographic  Plates,  with  Descriptive  Text  and  Notes  upon 
Treatment.  By  Tilbury  Fox,  M.  D.,  F.  R.  C.  P.,  Physician  to  the  Depart- 
ment for  Skin  Diseases  in  University  College  Hospital.     Folio  size. 

Price,  2.00  each,  or  complete,  bound  in  cloth,  price  30.00. 

Heath's  Operative  Surgery.  A  Course  of  Operative  Surgery,  consisting  of  a 
Series  of  Plates,  each  plate  containing  Numerous  Figures,  Drawn  from  Nature, 
Engraved  on  Steel,  and  Colored  by  Hand,  with  Descriptive  Text  of  Each 
Operation.  Complete  in  Five  Quarto  Parts,  each  containing  Four  Large  Plates, 
and  numerous  Figures.     Price  per  part,  2.50,  or  bound  in  one  vol.,  cloth,  14.00.' 

Hutchinson's  Illustrations  of  Clinical  Surgery.  Consisting  of  Plates,  Photo- 
graphs, Wood  Cuts,  Diagrams,  etc.,  illustrating  Surgical  Diseases,  Symptoms, 
and  Accidents  ;  also  Operations  and  other  Methods  of  Treatment.  With  Descrip- 
tive Letter-press.  Quarterly  Fasciculi.  Imperial  Quarto.  Parts  Oxe  to 
Fourteen  Now  Ready,  2.50  each  ;  or  the  first  ten  parts  bound  in  one  volume, 
complete  in  itself.  Price  25.00. 

Savage's  Surgery,  Surgical  Pathology,  and  Surgical  A7iatomy  of  the 
Female  Pelvic  Organs.  In  a  Series  of  Elegantly  Colored  Plates  and 
Diagrams  taken  from  Nature  ;  with  Commentaries,  Notes,  and  Cases.  Third 
Edition,  revised  and  greatly  extended.     A  large  4to  volume.  Price  12.00. 

Jones'  Aural  Atlas.  An  Atlas  of  Diseases  of  the  Membrana  Tympani. 
With  Sixty-three  Colored  Figures,  and  appropriate  letter-press.  Quarto, 
bound  in  cloth.  Price  6.00. 

Roberti  Froriepi's  Atlas  Anatomicus.  Containing  Thirty  Large  Plates,  in  all 
Seventy-six  Figures,  with  Full  References  to  the  Muscles,  Arteries,  Ligaments, 
etc.     One  Volume,  Quarto.    Colored  Plates,  10.00;   or  Plates  uncolored,  5.00. 

Godlee's  Atlas  of  Human  Anatomy.  Illustrating  most  of  the  ordinary 
Dissections  and  many  not  usually  practiced  by  the  Student.  Accompanied  by 
References  and  an  Explanatory  Text.  Complete.  Folio  Size.  48  Colored 
Plates.  Forming  a  large  Folio  Volume  with  References,  and  an  Octavo  Volume 
of  Letter-press.  Price  of  the  two  Volumes,  Atlas  and  Letter-press,  30.00. 
Sold  only  by  subscription. 

Martin's  Atlas  of  Obstetrics  and  Gyncecology.  Translated  and  Edited  from 
the  Second  German  Edition,  with  additions,  by  Fancourt  Barnes,  M.  D., 
M.  R.  C.  P.,  with  98  Full-page  Lithographic  Plates,  containing  over  400  Fig- 
ures, many  being  colored.  With  full  letter- press  references  to  and  explanations 
of  each  figure ;  forming  a  thick  quarto  volume.  Bound  in  heavy  beveled 
boards.    Price  12.00,  or  in  four  parts,  per  part,  3.00.    Sold  only  by  subscription. 


1 6  PRESLE  V  BLAKISTON'S  RECENT  PUBLIC  A  TIONS. 

THE 

AMERtCftN  SPECIALIST 

A  3Ionthly  tfournal  of  Medical  and  Surgical  Science, 


PUBLISHED  AT  $1.50  PEE  YEAE. 

TO     SXJBSCIilBEIlS. 

The  American  Specialist  is  addressed  to  general  practitioners,  in  the 
cities  and  in  the  country,  who  rarely  have  the  time,  and  in  many  cases  are 
without  the  opportunity,  to  cull  for  themselves  what  they  can  use  of  the 
information  now  accumulating  in  books  and  journals  devoted  to  special 
departments  of  medicine.  It  contains  abstracts  and  selections  from  American 
and  foreign  sources,  as  well  as  original  articles  from  authors  of  reputation, 
reports  of  clinics,  hospital  notes,  book  reviews,  criticisms,  etc.,  with  classified 
lists  of  current  medical  publications.  Illustrations  are  introduced  whenever 
they  seem  to  be  called  for. 

The  effort  is  to  present,  in  as  concise  a  form  as  possible,  matters  of 
practical  utility,  as  well  as  of  interest,  to  the  general  reader ;  while  it  is 
hoped  that  the  specialist  also  will  find  in  the  pages  of  this  journal  useful 
hints  in  regard  to  allied  departments  of  medicine,  as  well  as  a  suitable 
medium  for  communicating  facts  in  regard  to  his  own. 

TO    AI>VER.TISEP2,S. 

In  view  of  the  field  which  is  covered,  and  the  favor  with  which  the 
initial  numbers  of  The  American  Specialist  have  been  received,  it  will  be 
readily  seen  that  its  columns  afford  an  unusually  valuable  medium  through 
which  manufacturers  of  and  dealers  in  the  various  articles  required  by  the 
medical  profession  can  be  brought  to  its  notice.  The  circulation  is  steadily 
increasing  and  the  publishers  are  using  every  endeavor  to  make  the  journal 
valuable,  not  only  to  suj^scribers,  but  through  them  to  advertisers  also. 
During  the  year  all  the  available  physicians  and  pharmacists  in  the  United 
States  and  Canada  will  be  reached,  and  special  attention  will  be  paid  to  the 
different  departments  of  practice. 

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JPRESLEY  BLAKISTOJV,  JPiiblisher, 

No.  1012  Walnut  Street,  Philadelphia, 


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